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Traumatic Esophageal Perforation
Traumatic Esophageal Perforation William J. Rea, M.D., Gregory J. Gallivan, M.D., Roger R. Ecker, M.D., and W. L. Sugg, M.D. ABSTRACT Thirty-two consecutive unselected patients with traumatic esophageal perforation treated in the past seven years were reviewed. Perforation was due to gunshot wounds, stab wounds, instrumentation, or massive lye ingestion. Of the 12 patients seen in the first four years (Group I) who were treated with primary closure or tube thoracostomy, intravenous fluids, and antibiotics, 5 died. In a second group of 15 patients seen in the last three years (Group 11) who received 2,000 to 3,000 calories daily either intravenously or by tube feeding, only 1 patient died; 5 other patients with high, isolated injuries of the cervical esophagus who went home within one week were excluded from Group 11. The time from perforation to definitive therapy was approximately the same in both groups, as was the severity and type of perforation. Complications were similar in each group and included abscess, empyema, mediastinitis, hemorrhage, fistula, and pneumonia. Three times the associated injuries per person occurred in Group I1 as in Group I. Therefore there appeared to be a greater potential for complications and death, but only 1 of the 15 patients died as compared with 5 of the 12 Group I patients. This limited mortality appeared to be due to the increased nutritional regimen.
T
raumatic esophageal perforation is a serious condition that demands the clinician’s full talent and concentration. The mortality in various series has varied from 26% to 7% [l, 2, 5-7, 101. Advances in resuscitative measures and nutritional techniques prompted a review of our management of this condition [3, 43.
Materials and Met hod T h e case records of 32 consecutive, unselected patients with traumatic esophageal perforation who were treated at the University of Texas Southwestern Medical Teaching Hospitals in the past seven years were reviewed. Perforation was due to gunshot wounds in 14, stab wounds in 13, instrumentation in 3, and massive lye ingestion in 2. Ages ranged from 16 to 67 years, the average age being 36.8. T h e patients were divided into two groups according to the year treated and the therapy given. Group I consisted of 12 patients treated in the first four years of the study. They received conventional surgical treatment and a nutritional regimen of D6W intravenously. Group I1 consisted of 15 of From the Departments of Surgery, The University of Texas Southwestern Medical School and Veterans Administration Hospital, Dallas, Tex. Presented a t the Eighth Annual Meeting of T h e Society of Thoracic Surgeons, San Francisco, Calif., Jan. 24-26, 1972. Address reprint requests to Dr. Rea, Veterans Administration Hospital, 4500 S. Lancaster Rd., Dallas, Tex. 75216.
VOL.
14, NO. 6,
DECEMBER,
1972
671
REA ET AL. TABLE 1. LOCATION OF ASSOCIATED INJURIES IN 27 PATIENTS*
No. of Patients 9 7
Location Blood vessels Lung Trachea Nervous system Gastrointestinal system Ureter
4 4
3 1
*Four of the 12 Group I patients and I 3 of the 15 Group I1 patients had associated injuries.
the 20 patients seen in the last three years of the study who were treated with conventional surgical techniques and some type of hyperalimentation regimen, given either intravenously or by tube. Five patients seen in the last three years who received standard surgical therapy and only D6W as their nutritional regimen had isolated esophageal injuries of the neck, and all were discharged within one week. These patients are excluded from further discussion. In the Group I patients there were 4 gunshot wounds, 5 stab wounds, and 3 perforations due to instrumentation. T h e ages ranged from 16 to 67 years with an average of 36. Eight patients were treated immediately after injury, and 4 were treated from 2 to 24 days after injury. Four patients had associated injuries (Table l), and 9 had complications during therapy TABLE 2. POSTOPERATIVE COMPLICATIONS AND MORTALITY IN 27 PATIENTS
Complication Mediastinitis Empyema Pulmonary abscess Subdiaphragmatic abscess Gram-negative pneumonia Bronchopleural fistula Hemorrhage Esophagus Aorta Aspiration Pericarditis Parotiditis Small bowel fistula Perforated colon Renal vein thrombosis Fatty liver Stress ulcer (gastrectomy)
Group Ia Total Lived 3 0 2 1 0 ... 3 0 2 0 3 0
2
0 1 1 1 1
1
1
1
2
0
... 0 0
1
1 0 0 0 0
"Nineof the 12 patients had complications; 4 lived and 5 died. bAll 15 patients had complications; 1 died.
672
THE ANNALS OF THORACIC SURGERY
Group IIb Total Lived 9 9 8 8 3 3 6 6 7 7 3 3 1
1 1 0 0
3
1
0 0 1
0
1 0
...
... 3 1
... ... 1
Traumatic Esophageal Perforation
(Table 2). In the 4 patients with associated injuries there were 9 different areas of injury. In the Group I1 patients there were 8 gunshot wounds, 5 stab wounds, and 2 perforations due to massive lye ingestion. The ages ranged from 28 to 61 years with an average of 36.8 years. In this group, all patients were treated immediately after injury. Associated injury was frequent, occurring in 13 patients with 17 different injuries (see Table 1). Forty-four types of complications were found in the 15 patients (see Table 2).
Therapy Surgical therapy consisted of primary or secondary closure of the wound with adequate drainage. When primary closure was used, either one layer of catgut plus one layer of silk, one layer of silk alone, or two layers of silk was used. Secondary closure, done in only 3 patients, was always by closed tube thoracostomy without suture. The same closures were used in both groups. Conventional therapy of D5W given intravenously was used in Group I only, with the patient receiving no more than 600 calories per day. Hyperalimentation either by tube or intravenously was given only to patients in Group 11. Tube feedings consisted of a balanced solution of protein, carbohydrates, and fat (1 calorie per cubic milliliter). Each patient received between 2,000 and 3,000 calories daily through a Levin, gastrostomy, or jejunostomy tube. One patient received feedings through each of these routes. Twelve patients received between 2,000 and 3,000 calories daily through a central venous catheter. The solution consisted of fibrin or casein hydrolysates containing 6 gm. per liter of nitrogen and 200 gm. per liter of dextrose with a total caloric value of approximately 1,000 calories per bottle. Treatment lasted from 7 to 90 days. Daily weight and nitrogen balance was measured in the majority of Group 11 patients (Figure). All patients in both groups had antibiotic coverage, both broad-spectrum and for gram-negative organisms.
R esu 1ts Five of the 12 patients in Group I died. Of these, 3 patients had sustained stab wounds and 2 had had perforation from instrumentation. Their ages ranged from 33 to 67 years with an average age of 51 years; in contrast, the patients who lived ranged in age from 16 to 48 years with an average age of 26.4. Among the survivors, 5 patients had been treated immediately and 2 from 16 to 24 days following injury, while among those who died, 3 patients had been treated immediately and 2 in 48 hours. Three patients in the survivor group and 1 patient who died had associated injuries. Four Group I patients who had severe complications survived, while 5 died. Of those 5, 3 patients developed mediastinitis followed by other septic complicaVOL.
14, NO. 6, DECEMBER, 1972
673
KEA E T AL.
16'.
. .
0 2
DAY
N in(1.V.) N out
WEIGHT(1bs)
2 10 1 2 6 108 1 1 1
0
o
.
. . . .
.
.
3 4 5 6 9 1011 1213 DAYS
3 10 5 112
4
6 10 9 110 112 113
10 8
5
10
8
9 13 9 113
1 0 13 1 3 115
1 1 1 2 1 3 9 9 10 9 1 2 5 117 116 115
Postoperative nitrogen balance in Group 11 patients receiving Dudrick's solution (conlaining 6 gm. per liter of nitrogen and 200 gm. per liter of dextrose).
tions until death occurred. The other 2 patients had empyema and subdiaphragmatic abscess followed by gram-negative septicemia, pneumonia, and death. In Group 11, all patients except 1 survived. The patient who died was a 36-year-old man who had had perforation from a massive lye burn. He had done well and was eating when suddenly one day he vomited blood, aspirated, and died. The 3 patients who received tube feedings had injuries of the lower esophagus, more complications, and associated injuries. The 12 patients who received Dudrick's solution [3, 4, 8, 91 were treated for massive injuries of other organs, such as the spleen, colon, small bowel, trachea, bronchus, lung, and large blood vessels, in addition to the perforation of the thoracic esophagus (see Table 1). They had mediastinal abscess, empyema, subphrenic abscess, and gram-negative pneumonia in addition to the esophageal perforation or fistula (see Table 2). Once hyperalimentation was started, weight gain varied from 0 to 30 pounds in this group. Positive nitrogen balance was obtained in all the patients who received hyperalimentation (Figure). In some patients, complete healing took from several days to weeks. There were 2 complications related to the intravenous therapy. The first was an allergic reaction producing urticaria that disappeared with cessation of the fluid. Hyperalimentation was continued with another type of solution. The second complication was sepsis resulting from a catheter being reintro674
THE ANNALS OF THORACIC SURGERY
Traumatic Esophageal Perforation
duced through an old catheter channel. Obviously, this was a technical error; however, the patient survived.
Commen t Age may be a factor in death from esophageal perforation. Though the average age was the same in both groups (36 years), the 5 Group I patients who died were older, with an average age of 51 years. The only death in Group I1 was of a patient aged 36. Since the 5 patients in Group I1 who were in the fifth or sixth decade survived, age probably did not have much effect on mortality in this series when adequate nutrition was maintained. The time from injury to treatment has always been known to affect mortality [lo]. If one compares survival versus death in Groups I and 11, this axiom appears not to hold, though 2 of the deaths in Group I were clearly related to delay in therapy. We still believe this basic principle to be important, since all patients treated in the last three years except those with lye burns underwent closure as soon as possible after injury. One would suspect associated injuries to be a factor in increasing the mortality in either group. There were many more injuries in Group I1 than in Group I, however, and these were larger and caused more complications. Several Group I1 patients survived their initial trauma because of newer resuscitative techniques. It appears that although the patients in Group I1 had more complications and associated injuries, they were able to handle them better because of adequate nutrition. Eight of these patients were treated for up to three months on account of their complications and survived. In the past, these patients probably would have died because of the lethal nature of their complications, i.e., mediastinitis. Nine patients in Group I1 had mediastinitis and all survived, as compared with no survivors in Group I. Some of these patients also had bronchopleural and esophageal fistulas. Further evidence to support the influence of nutrition on survival is the fact that all 7 patients who had gram-negative pneumonia as well as other associated complications lived. It appeared that if one could treat each episode of sepsis as it arose and yet maintain adequate nutrition, the patient would be able to survive. It must be emphasized that when a patient is receiving hyperalimentation, one must take meticulous care of the central venous catheter at the time of insertion, using adequate sterile techniques. Maintaining clean dressings is also an important factor. The catheter should be removed with each new episode of sepsis, and blood cultures and cultures of the catheter tip should be obtained. The immediate reinsertion of a new catheter in another site and continuation of the hyperalimentation without delay are important. A constant flow of intravenous solution over a 24-hour period will aid in maximal caloric and nitrogen utilization. Many patients did not have their hyperalimentation started until comVOL.
14,
NO.
6,
DECEMBER,
1972
675
REA E T AL. plications had developed. With better initial resuscitative techniques, more patients with massive injuries will survive. These patients should be selected as being prone to complications. It would be interesting to start hyperalimentation immediately after operation on their traumatic perforation and see if many of the complications could be prevented.
References 1. Bobo, W. O., Billups, W. A., and Hardy, J. D. Boerhaave's syndrome: A review of six cases of spontaneous rupture of the esophagus secondary to vomiting. Ann. Surg. 172: 1034, 1970. 2. Borja, A. R., Ransdell, H. T., Jr., Thomas, T. V., and Johnson, W. Lye injuries of the esophagus. J . Thorac. Cardiovasc. Surg. 57:533, 1969. 3. Dudrick, S. J., Vars, H. M., and Rhoads, J. E. Growth of puppies receiving all nutritional requirements by vein. Fortschr. Parenter. Ernahr. 2: 16, 1967. 4. Dudrick, S. J., Wilmore, D. W., and Vars, H. M. Long-term total parenteral nutrition with growth in puppies and positive nitrogen balance in patients. Surg. Forum 18:356, 1967. 5. Kaiser, G. A., Bowman, F. O., Jr., and Wylie, R. H. Definitive surgery for the treatment of esophageal perforation with distal obstruction. Ann. Thorac. Surg. 8:75, 1969. 6. Paulson, D. L., Shaw, R. R., and Kee, J. L. Recognition and treatment of esophageal perforations. Ann. Surg. 152: 13, 1960. 7. Quintana, R., Bartley, T. D., and Wheat, M. W., Jr. Esophageal perforation: Analysis of 10 cases. Ann. Thorac. Surg. 10:45, 1970. 8. Rea, W. J., Wyrick, W. J., McClelland, R. N., and Webb, W. R. Intravenous hyperosmolar alimentation. Arch. Surg. 100:393, 1970. 9. Wilmore, D. W., Groff, D. B., Bishop, H. C., and Dudrick, S. J. Total parenteral nutrition in infants with catastrophic gastrointestinal anomalies. J . Pediatr. Surg. 4:181, 1969. 10. Youngs, J., and Nicoloff, D. Management of esophageal perforation. Surgery 65264, 1969.
Discussion DR. ROBERT F. WILSON (Detroit, Mich.): In our own series of 68 patients with esophageal perforations who have been treated during the past ten years, death was related to late diagnosis, inadequate drainage, associated injuries, or severe associated diseases. At Wayne State Affiliated Hospitals in Detroit within the past ten years, we have seen 26 patients with spontaneous perforation, of whom 16 died. In all except 2 of the patients who died there was a delay in diagnosis. Of 42 patients with traumatic perforation, only 5 died. Of 11 patients who had perforation due to diagnostic esophagoscopy (8 for benign disease and 3 for carcinoma), 1 with carcinoma died. Of 10 patients who sustained perforation during dilatation of stricture (7 from lye, 2 from esophagitis, and 1 from cancer) 1 (the cancer patient) died. There were 11 gunshot wounds of the esophagus, 7 in the neck and 4 in the chest. One patient died suddenly of hemorrhage from wounds of the aorta and heart. The other death occurred from hemorrhage through an aortoesophageal fistula seven weeks after repair of the esophageal and aortic lesions. Of 4 patients who were stabbed in the esophagus, none died. Of 4 with foreign body perforations, none died. Of 2 patients who received their perforation during an abdominal vagotomy, 1 died. An extremely high index of suspicion is needed to make the diagnosis, and 676
THE ANNALS OF THORACIC SURGERY
Traumatic Esophageal Perforation it is greatly aided if there is a sudden onset of chest pain or any subcutaneous air. T h e plain chest and lateral neck films show abnormal air locations best; however, perforation of strictures due to lye ingestion may cause few or no changes on plain roentgenograms. The incidence of false-negative Gastrografin swallows in our series was almost 10%; we have had no false-negative results with barium swallows. If possible, the perforation should be repaired within 8 to 12 hours, in two layers, and then patched. If the perforation is in the middle or upper esophagus, we use a pleural patch; in the lower esophagus, the Thal gastric fundus patch is best, and it allows a more delayed closure. It is important to have the Thal patch cover about two-thirds to three-quarters of the circumference of the esophagus. If the patient has high acid levels or a history of ulcer, a pyloroplasty and vagotomy may also be done. If the perforation occurs in the chest, the mediastinum and pleural cavity should be drained using one or two tubes. If sepsis continues, a small thoracotomy is done to place the tubes more accurately. It is important to decompress the stomach, especially if the perforation is in the lower chest. A sump gastrostomy is especially effective for emptying the stomach and preventing reflux onto and through the perforation. Most of the problem with continued sepsis is probably from regurgitation of gastric contents (not the swallowing of saliva) and undrained collections. A cervical esophagostomy may be important if there is continued sepsis, especially if a colon bypass is planned for later. We avoid Levin tubes except for perforations in the neck and when it is not possible to do a gastrostomy. T h e Levin tube causes more respiratory complications by increasing secretions, and it may also act as a conduit for regurgitation of gastric contents around it. If the perforation is associated with a benign stricture, we try to get a string through the stricture. This is best done by tying a string to the tip of a bougie and then passing the bougie u p retrograde from the stomach. We usually wait at least 5 to 7 days to feed these patients by mouth, and then do so only if the barium swallow looks completely normal. Most of these patients require respiratory support with high tidal volumes, and they should not be overloaded with fluids. Intravenous hyperalimentation of 3,000 or more calories per day appears to be an important adjunct to therapy, but we usually begin it only after the sepsis is controlled. We have had a number of complications with intravenous hyperalimentation, especially when we first began. Our biggest problems have been sepsis, glucose intolerance (especially in elderly, diabetic, and septic patients), polyuria, and dehydration. I would just like for the author to comment on some of these technical aspects of management and some of the problems he has had with intravenous hyperalimentation.
DR. REA:I agree that hyperalimentation can be dangerous. I said that in this particular series we saw only 1 rash due to hypersensitivity and 1 episode of sepsis, which was due to a technical error. However, we have had other severe complications referred to us. We saw a patient with Candida albicans and aortic valvulitis that necessitated aortic valve replacement. We have also had 5 patients referred to us with broken central venous catheters in either the right ventricle or the pulmonary artery.
VOL.
14,
NO.
6,
DECEMBER, 1 9 7 2
677
T
raumatic esophageal perforation is a serious condition that demands the clinician’s full talent and concentration. The mortality in various series has varied from 26% to 7% [l, 2, 5-7, 101. Advances in resuscitative measures and nutritional techniques prompted a review of our management of this condition [3, 43.
Materials and Met hod T h e case records of 32 consecutive, unselected patients with traumatic esophageal perforation who were treated at the University of Texas Southwestern Medical Teaching Hospitals in the past seven years were reviewed. Perforation was due to gunshot wounds in 14, stab wounds in 13, instrumentation in 3, and massive lye ingestion in 2. Ages ranged from 16 to 67 years, the average age being 36.8. T h e patients were divided into two groups according to the year treated and the therapy given. Group I consisted of 12 patients treated in the first four years of the study. They received conventional surgical treatment and a nutritional regimen of D6W intravenously. Group I1 consisted of 15 of From the Departments of Surgery, The University of Texas Southwestern Medical School and Veterans Administration Hospital, Dallas, Tex. Presented a t the Eighth Annual Meeting of T h e Society of Thoracic Surgeons, San Francisco, Calif., Jan. 24-26, 1972. Address reprint requests to Dr. Rea, Veterans Administration Hospital, 4500 S. Lancaster Rd., Dallas, Tex. 75216.
VOL.
14, NO. 6,
DECEMBER,
1972
671
REA ET AL. TABLE 1. LOCATION OF ASSOCIATED INJURIES IN 27 PATIENTS*
No. of Patients 9 7
Location Blood vessels Lung Trachea Nervous system Gastrointestinal system Ureter
4 4
3 1
*Four of the 12 Group I patients and I 3 of the 15 Group I1 patients had associated injuries.
the 20 patients seen in the last three years of the study who were treated with conventional surgical techniques and some type of hyperalimentation regimen, given either intravenously or by tube. Five patients seen in the last three years who received standard surgical therapy and only D6W as their nutritional regimen had isolated esophageal injuries of the neck, and all were discharged within one week. These patients are excluded from further discussion. In the Group I patients there were 4 gunshot wounds, 5 stab wounds, and 3 perforations due to instrumentation. T h e ages ranged from 16 to 67 years with an average of 36. Eight patients were treated immediately after injury, and 4 were treated from 2 to 24 days after injury. Four patients had associated injuries (Table l), and 9 had complications during therapy TABLE 2. POSTOPERATIVE COMPLICATIONS AND MORTALITY IN 27 PATIENTS
Complication Mediastinitis Empyema Pulmonary abscess Subdiaphragmatic abscess Gram-negative pneumonia Bronchopleural fistula Hemorrhage Esophagus Aorta Aspiration Pericarditis Parotiditis Small bowel fistula Perforated colon Renal vein thrombosis Fatty liver Stress ulcer (gastrectomy)
Group Ia Total Lived 3 0 2 1 0 ... 3 0 2 0 3 0
2
0 1 1 1 1
1
1
1
2
0
... 0 0
1
1 0 0 0 0
"Nineof the 12 patients had complications; 4 lived and 5 died. bAll 15 patients had complications; 1 died.
672
THE ANNALS OF THORACIC SURGERY
Group IIb Total Lived 9 9 8 8 3 3 6 6 7 7 3 3 1
1 1 0 0
3
1
0 0 1
0
1 0
...
... 3 1
... ... 1
Traumatic Esophageal Perforation
(Table 2). In the 4 patients with associated injuries there were 9 different areas of injury. In the Group I1 patients there were 8 gunshot wounds, 5 stab wounds, and 2 perforations due to massive lye ingestion. The ages ranged from 28 to 61 years with an average of 36.8 years. In this group, all patients were treated immediately after injury. Associated injury was frequent, occurring in 13 patients with 17 different injuries (see Table 1). Forty-four types of complications were found in the 15 patients (see Table 2).
Therapy Surgical therapy consisted of primary or secondary closure of the wound with adequate drainage. When primary closure was used, either one layer of catgut plus one layer of silk, one layer of silk alone, or two layers of silk was used. Secondary closure, done in only 3 patients, was always by closed tube thoracostomy without suture. The same closures were used in both groups. Conventional therapy of D5W given intravenously was used in Group I only, with the patient receiving no more than 600 calories per day. Hyperalimentation either by tube or intravenously was given only to patients in Group 11. Tube feedings consisted of a balanced solution of protein, carbohydrates, and fat (1 calorie per cubic milliliter). Each patient received between 2,000 and 3,000 calories daily through a Levin, gastrostomy, or jejunostomy tube. One patient received feedings through each of these routes. Twelve patients received between 2,000 and 3,000 calories daily through a central venous catheter. The solution consisted of fibrin or casein hydrolysates containing 6 gm. per liter of nitrogen and 200 gm. per liter of dextrose with a total caloric value of approximately 1,000 calories per bottle. Treatment lasted from 7 to 90 days. Daily weight and nitrogen balance was measured in the majority of Group 11 patients (Figure). All patients in both groups had antibiotic coverage, both broad-spectrum and for gram-negative organisms.
R esu 1ts Five of the 12 patients in Group I died. Of these, 3 patients had sustained stab wounds and 2 had had perforation from instrumentation. Their ages ranged from 33 to 67 years with an average age of 51 years; in contrast, the patients who lived ranged in age from 16 to 48 years with an average age of 26.4. Among the survivors, 5 patients had been treated immediately and 2 from 16 to 24 days following injury, while among those who died, 3 patients had been treated immediately and 2 in 48 hours. Three patients in the survivor group and 1 patient who died had associated injuries. Four Group I patients who had severe complications survived, while 5 died. Of those 5, 3 patients developed mediastinitis followed by other septic complicaVOL.
14, NO. 6, DECEMBER, 1972
673
KEA E T AL.
16'.
. .
0 2
DAY
N in(1.V.) N out
WEIGHT(1bs)
2 10 1 2 6 108 1 1 1
0
o
.
. . . .
.
.
3 4 5 6 9 1011 1213 DAYS
3 10 5 112
4
6 10 9 110 112 113
10 8
5
10
8
9 13 9 113
1 0 13 1 3 115
1 1 1 2 1 3 9 9 10 9 1 2 5 117 116 115
Postoperative nitrogen balance in Group 11 patients receiving Dudrick's solution (conlaining 6 gm. per liter of nitrogen and 200 gm. per liter of dextrose).
tions until death occurred. The other 2 patients had empyema and subdiaphragmatic abscess followed by gram-negative septicemia, pneumonia, and death. In Group 11, all patients except 1 survived. The patient who died was a 36-year-old man who had had perforation from a massive lye burn. He had done well and was eating when suddenly one day he vomited blood, aspirated, and died. The 3 patients who received tube feedings had injuries of the lower esophagus, more complications, and associated injuries. The 12 patients who received Dudrick's solution [3, 4, 8, 91 were treated for massive injuries of other organs, such as the spleen, colon, small bowel, trachea, bronchus, lung, and large blood vessels, in addition to the perforation of the thoracic esophagus (see Table 1). They had mediastinal abscess, empyema, subphrenic abscess, and gram-negative pneumonia in addition to the esophageal perforation or fistula (see Table 2). Once hyperalimentation was started, weight gain varied from 0 to 30 pounds in this group. Positive nitrogen balance was obtained in all the patients who received hyperalimentation (Figure). In some patients, complete healing took from several days to weeks. There were 2 complications related to the intravenous therapy. The first was an allergic reaction producing urticaria that disappeared with cessation of the fluid. Hyperalimentation was continued with another type of solution. The second complication was sepsis resulting from a catheter being reintro674
THE ANNALS OF THORACIC SURGERY
Traumatic Esophageal Perforation
duced through an old catheter channel. Obviously, this was a technical error; however, the patient survived.
Commen t Age may be a factor in death from esophageal perforation. Though the average age was the same in both groups (36 years), the 5 Group I patients who died were older, with an average age of 51 years. The only death in Group I1 was of a patient aged 36. Since the 5 patients in Group I1 who were in the fifth or sixth decade survived, age probably did not have much effect on mortality in this series when adequate nutrition was maintained. The time from injury to treatment has always been known to affect mortality [lo]. If one compares survival versus death in Groups I and 11, this axiom appears not to hold, though 2 of the deaths in Group I were clearly related to delay in therapy. We still believe this basic principle to be important, since all patients treated in the last three years except those with lye burns underwent closure as soon as possible after injury. One would suspect associated injuries to be a factor in increasing the mortality in either group. There were many more injuries in Group I1 than in Group I, however, and these were larger and caused more complications. Several Group I1 patients survived their initial trauma because of newer resuscitative techniques. It appears that although the patients in Group I1 had more complications and associated injuries, they were able to handle them better because of adequate nutrition. Eight of these patients were treated for up to three months on account of their complications and survived. In the past, these patients probably would have died because of the lethal nature of their complications, i.e., mediastinitis. Nine patients in Group I1 had mediastinitis and all survived, as compared with no survivors in Group I. Some of these patients also had bronchopleural and esophageal fistulas. Further evidence to support the influence of nutrition on survival is the fact that all 7 patients who had gram-negative pneumonia as well as other associated complications lived. It appeared that if one could treat each episode of sepsis as it arose and yet maintain adequate nutrition, the patient would be able to survive. It must be emphasized that when a patient is receiving hyperalimentation, one must take meticulous care of the central venous catheter at the time of insertion, using adequate sterile techniques. Maintaining clean dressings is also an important factor. The catheter should be removed with each new episode of sepsis, and blood cultures and cultures of the catheter tip should be obtained. The immediate reinsertion of a new catheter in another site and continuation of the hyperalimentation without delay are important. A constant flow of intravenous solution over a 24-hour period will aid in maximal caloric and nitrogen utilization. Many patients did not have their hyperalimentation started until comVOL.
14,
NO.
6,
DECEMBER,
1972
675
REA E T AL. plications had developed. With better initial resuscitative techniques, more patients with massive injuries will survive. These patients should be selected as being prone to complications. It would be interesting to start hyperalimentation immediately after operation on their traumatic perforation and see if many of the complications could be prevented.
References 1. Bobo, W. O., Billups, W. A., and Hardy, J. D. Boerhaave's syndrome: A review of six cases of spontaneous rupture of the esophagus secondary to vomiting. Ann. Surg. 172: 1034, 1970. 2. Borja, A. R., Ransdell, H. T., Jr., Thomas, T. V., and Johnson, W. Lye injuries of the esophagus. J . Thorac. Cardiovasc. Surg. 57:533, 1969. 3. Dudrick, S. J., Vars, H. M., and Rhoads, J. E. Growth of puppies receiving all nutritional requirements by vein. Fortschr. Parenter. Ernahr. 2: 16, 1967. 4. Dudrick, S. J., Wilmore, D. W., and Vars, H. M. Long-term total parenteral nutrition with growth in puppies and positive nitrogen balance in patients. Surg. Forum 18:356, 1967. 5. Kaiser, G. A., Bowman, F. O., Jr., and Wylie, R. H. Definitive surgery for the treatment of esophageal perforation with distal obstruction. Ann. Thorac. Surg. 8:75, 1969. 6. Paulson, D. L., Shaw, R. R., and Kee, J. L. Recognition and treatment of esophageal perforations. Ann. Surg. 152: 13, 1960. 7. Quintana, R., Bartley, T. D., and Wheat, M. W., Jr. Esophageal perforation: Analysis of 10 cases. Ann. Thorac. Surg. 10:45, 1970. 8. Rea, W. J., Wyrick, W. J., McClelland, R. N., and Webb, W. R. Intravenous hyperosmolar alimentation. Arch. Surg. 100:393, 1970. 9. Wilmore, D. W., Groff, D. B., Bishop, H. C., and Dudrick, S. J. Total parenteral nutrition in infants with catastrophic gastrointestinal anomalies. J . Pediatr. Surg. 4:181, 1969. 10. Youngs, J., and Nicoloff, D. Management of esophageal perforation. Surgery 65264, 1969.
Discussion DR. ROBERT F. WILSON (Detroit, Mich.): In our own series of 68 patients with esophageal perforations who have been treated during the past ten years, death was related to late diagnosis, inadequate drainage, associated injuries, or severe associated diseases. At Wayne State Affiliated Hospitals in Detroit within the past ten years, we have seen 26 patients with spontaneous perforation, of whom 16 died. In all except 2 of the patients who died there was a delay in diagnosis. Of 42 patients with traumatic perforation, only 5 died. Of 11 patients who had perforation due to diagnostic esophagoscopy (8 for benign disease and 3 for carcinoma), 1 with carcinoma died. Of 10 patients who sustained perforation during dilatation of stricture (7 from lye, 2 from esophagitis, and 1 from cancer) 1 (the cancer patient) died. There were 11 gunshot wounds of the esophagus, 7 in the neck and 4 in the chest. One patient died suddenly of hemorrhage from wounds of the aorta and heart. The other death occurred from hemorrhage through an aortoesophageal fistula seven weeks after repair of the esophageal and aortic lesions. Of 4 patients who were stabbed in the esophagus, none died. Of 4 with foreign body perforations, none died. Of 2 patients who received their perforation during an abdominal vagotomy, 1 died. An extremely high index of suspicion is needed to make the diagnosis, and 676
THE ANNALS OF THORACIC SURGERY
Traumatic Esophageal Perforation it is greatly aided if there is a sudden onset of chest pain or any subcutaneous air. T h e plain chest and lateral neck films show abnormal air locations best; however, perforation of strictures due to lye ingestion may cause few or no changes on plain roentgenograms. The incidence of false-negative Gastrografin swallows in our series was almost 10%; we have had no false-negative results with barium swallows. If possible, the perforation should be repaired within 8 to 12 hours, in two layers, and then patched. If the perforation is in the middle or upper esophagus, we use a pleural patch; in the lower esophagus, the Thal gastric fundus patch is best, and it allows a more delayed closure. It is important to have the Thal patch cover about two-thirds to three-quarters of the circumference of the esophagus. If the patient has high acid levels or a history of ulcer, a pyloroplasty and vagotomy may also be done. If the perforation occurs in the chest, the mediastinum and pleural cavity should be drained using one or two tubes. If sepsis continues, a small thoracotomy is done to place the tubes more accurately. It is important to decompress the stomach, especially if the perforation is in the lower chest. A sump gastrostomy is especially effective for emptying the stomach and preventing reflux onto and through the perforation. Most of the problem with continued sepsis is probably from regurgitation of gastric contents (not the swallowing of saliva) and undrained collections. A cervical esophagostomy may be important if there is continued sepsis, especially if a colon bypass is planned for later. We avoid Levin tubes except for perforations in the neck and when it is not possible to do a gastrostomy. T h e Levin tube causes more respiratory complications by increasing secretions, and it may also act as a conduit for regurgitation of gastric contents around it. If the perforation is associated with a benign stricture, we try to get a string through the stricture. This is best done by tying a string to the tip of a bougie and then passing the bougie u p retrograde from the stomach. We usually wait at least 5 to 7 days to feed these patients by mouth, and then do so only if the barium swallow looks completely normal. Most of these patients require respiratory support with high tidal volumes, and they should not be overloaded with fluids. Intravenous hyperalimentation of 3,000 or more calories per day appears to be an important adjunct to therapy, but we usually begin it only after the sepsis is controlled. We have had a number of complications with intravenous hyperalimentation, especially when we first began. Our biggest problems have been sepsis, glucose intolerance (especially in elderly, diabetic, and septic patients), polyuria, and dehydration. I would just like for the author to comment on some of these technical aspects of management and some of the problems he has had with intravenous hyperalimentation.
DR. REA:I agree that hyperalimentation can be dangerous. I said that in this particular series we saw only 1 rash due to hypersensitivity and 1 episode of sepsis, which was due to a technical error. However, we have had other severe complications referred to us. We saw a patient with Candida albicans and aortic valvulitis that necessitated aortic valve replacement. We have also had 5 patients referred to us with broken central venous catheters in either the right ventricle or the pulmonary artery.
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