s~ .
Journal of the Royal Society of Medicine Volume 85 January 1992
Case reports
Oesophageal perforation complicated by bilateral empyemas - an alternative management strategy
P Kallis FRCS J A C Chalmers FRCS A J Wood FRCS Department of Cardiothoracic Surgery, The Royal London Hospital, London El lBB Keywords: oesophageal perforation; empyema
Instrumental perforation of the oesophagus carries a high morbidity and mortality'. An interval longer than 36 h between perforation and treatment is associated with 50% mortality3. Particularly difficult to manage are oesophageal perforations associated with fistulae and suppuration following attempted repair4. We report such a case complicated by bilateral empyemas, referred to us one month after attempted repair, managed successfully using an alternative management strategy.
Case report A 66-year-old woman presented to another hospital with a 2-year history of reflux oesophagitis and dysphagia. A barium swallow revealed a hiatus hernia and a benign oesophageal stricture confirmed by multiple biopsies. During oesophagoscopic dilatation perforation was suspected.
At laparotomy perforation of the lower oesophagus was repaired, the hiatus hernia reduced and fundoplication performed. Four days later she became pyrexial and dyspnoeic. A chest radiograph revealed bilateral pleural effusions and gastrografin swallow (Figure 1) demonstrated free egress of contrast into both pleural spaces. Conservative management consisting of intercostal drainage, antibiotics and parenteral nutrition resulted in initial improvement but 4 weeks later she deterioratecl and was transferred to the London Hospital. On admission she was toxic and had bilateral pleural effusions (Figure 2). Review of all X-rays revealed complete obstruction ofthe lower oesophagus with bilateral oesophagopleural fistulae (Figure 1). Drainage of large quantities of pus was accomplished by insertion ofbilateral intercostal drains. The pleural spaces were irrigated by infusion of isotonic saline, through a naso-oesophageal tube, which drained via the intercostal drains. Two weeks later she was apyrexial and fit to undergo oesophageal bypass. At laparotomy the stomach was mobilized, the oesophagogastric junction transected and the proximal end oversewn. The cervical oesophagus was mobilized through a left cervical incision, transected and the distal end oversewn, thus isolating the thoracic oesophagus. Gastrointestnal continuity was restored by tunnelling the stomach retrsternally and performing gastro-oesophageal anastomosis in the neck. One week later the patient was eating normally. Three weeks after oesophageal bypass, oesophagectomy and decortication was performed through a right thoracotomy. The right chest drains were removed on the 5th postoperative day. The left chest drain was-gradually shortened while draining into colostomy bags and removed a month later. Two months after transfer to The London Hospital she was discharged home. Dilatation of an anastomotic stricture was required twice in the first year but she remains asymptomatic 2 years later.
41
Case presented to Clinical Section, 9 November 1990
Discussion The major prognostic factors of oesophageal perforations are: ) the interval between perforation and treatment, (ii) the anatomical site of perforation, (iii) pro-existing oesophageal obstruction, (iv) the modality of treatment, and (v) the Xexperience of the managing team4. ln this case immediate repair was attempted whereas many authors`17 recommend resectioci of the stricture and primary oesophagogastric anastomosis. Such an approach treats both perforation and stricture in one stage.
o,...A
Figure 1. Gastrografin swallow showing bilateral oesophagopleural fistulae and distal oesophageal obstruction
Correspondence to: Mr P Kallis, Department of Cardiothoracic Surgery, St- George's Hospital, London SW17 OQT
i.
Figure2. Chest radiograph showing large bilateral pleural effusions
0141-0768/92/
010041-02/$02.00/0 X) 1992 The Royal Society of Medicine
42
Journal of the Royal Society of Medicine Volume 85 January 1992
Once gross sepsis is present a two-staged procedure is favoured5-7. During the first stage the oesophagus is resected, the oesophagogastric junction closed and the thoracic cavity debrided. An end cervical oesophagostomy and a feeding gastrostomy complete the procedure. Three months later gastrointestinal continuity is restored by colonic
with meticulous planning adopting established principles as no treatment is applicable to all patients. This case demonstrates an alternative management strategy that increases the armamentarium of the team managing oesophageal perforations associated with bilateral sepsis.
interposition between the cervical oesophagus and the stomach. On transfer to our department this patient was already one month post repair and with established sepsis. We approached the problem in three stages and in the reverse order. Firstly the general condition of the patient was improved, then normal gatrointestinal function restored and finally the oesophagus resected. This approach offers several advantages by avoiding: (i) cervical oesophagostomy, (ii) feeding gastrostomy (iii) the contaminated posterior mediastinum during reconstruction and (iv) left decortication. It also establishes normal gastrointestinal function earlier and shortens the overall treatment period. Resecting the oesophagus last necessitates the presence of chest drains for longer but the morbidity is reduced by cutting the drains and allowing drainage into colostomy bags. Oesophageal perforation carries a high mortality, especially when associated with sepsis. Good results can be achieved
References 1 Craddock DR, Logan A, Myell M. Traumatic rupture of the oesophagus and stomach. Thorax 1968;23:657-62 2 Sandrasagra FA, English TAH, Milstein BB. The management and prognosis of oesophageal perforation. Br J Surg 1978; 65:629-32 3 Goldstein LA, Thompson WR. Esophageal perforations: A 15 year experience. Am J Surg 1982;143:495-503 4 Moghissi K. Instrumental perforations of the oesophagus. Br J Hosp Med 1988;March:231-6 5 Keen G. The surgical management of old oesophageal perforations. J Thorac Cardiovasc Surg 1968;56:603-6 6 Triggiani E, Belsey R. Oesophageal trauma incidence - diagnosis and management. Thorax 1977;32:241-9 7 Brewer LA, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the oesophagus. Am J Surg 1986;152;62-9
Normogastrinaemic gastric hypersecretion with recurrent and fistulating jejunal ulcer
(Accepted 14 August 1991)
Radne Lv.Lv
IO
Ow
1azo
200 mgMd
80 m/d-I.v.
20 md-oral
120 mgl - i.v.
3200
8
Case presented to Clinical Section, 9 November 1990
2800
~*2400
P Rao MB BS1 J H Baron FRCP FRCS2 G Glazer MS FRCS' Departments of 'Surgery and 2Gastroenterology, St Mary's Hospital, London W2 INY
6
E20000
1800~~~~~~~~~~~~~~~~ ~1600 41 120
_
1501
400.
100 50 0i
0
Keywords: gastric hypersecretion; normogastrinaemia; intestinal fistula; omeprazole
0 1990 -
2 -6
Jawwy
12
t8
P=
M
30
0 5
k
Figure 1. Effeetof drug treatmentii8fie4 volume and acid output
We describe a patient with chronic pancreatitis, normogastrinaemic gastric hypersecretion, and a recurrent and spontaneously fistulating jejunal ulcer which responded to intravenous but not oral ameprazole. Even after excision of the fistula, truncal vagotomy and antrectomy his gastric hypersecretion continues. Case report This 41-year-old male smoker with a long history of heavy alcohol intake first presentei in 1983 with obstructive of the pancreas. This; jaundice due to a cyst ain tb but in February resolved with conservative m 1986 he developed recurrent ouctivejandice and gastrij outflow obstruction secondary to a pancreatic pseudocyst. A gastrojejunostomy and cholecystojejunostomy with a Puestow procedure relieved his symptoms. He had no pas or family history of ulcer or endocrine disease. In November 1986 he presented with an epigastric mass due to a penetrating ulcer in the jejunum immediately adjacent to the gastrojejunostomy. The ulcer was oversewn and he remained symptom free for one year on ranitidine 150 mg twice a day. After stopping ranitidine his pains returned with further induration around the laparotomy scar due to recurrence of the ulcer just beyond the gastrojejunostomy, and he was again advised long-term ranitidine. Correspondence to: Dr J H Baron
Gastric secretion tests in 198T(when off ranitidine) showed high basal (6.2 mmol/h) and peak (73 mmol) acid outputs but normal serum gastni4{4 Fuel) ahd calcium (2.4 mmol/l). In December 1989 whilI uganitidiuebIe presented with weight loss-of 5 kgin3weekea ano-pigastric fistula discrging 800-900 ml cW kWid4 1,t *Endosopy again showed ulcerationi on"ite jejuijal aideof the gastrojejunostomy in continuity*itbthe fistula. hiiia treatment with parenteral nutrition and intravenou ifusion of ranitidine 200 mg/24 hlib sofct hion i or fistula onW ~t1Ora omeprazole 20 mg capsules day h4dnieffect & acid output because the-caples pissed""" e into the 'stula drainag ags.- Howeer, om4ze by I 4h, then intravenous infusion,' (n lh 4 40 mg/12 h), abolishe pcoinad na cmpletely inhibited acidily (pH 6.0) thre was a it increase in the voluie of fistula fluid (gre 1) On 5 February 1990 afr 1das of oazole the fistula ot my d antrectomy was excised and a tUMcal performed. Nevertheli, in Ma-y he still had normobypers (basal gastrinaemic (4 pmoW) ga 17.1 mmol/h, peak 32.1 mmol/h), and he is being kept symptom free on mainten e ranitidie 150 mg twice a day. Discussion
Spontaneoub gastrointestinal fistulae are extremely rare. The aetiology is unknown. As far back as 1797 Jacob Helm of Vienna began experiments on the persistent gastric fistula
0141-0768/92/ 010042-02/$02.00/0 © 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 January 1992
Case reports
Oesophageal perforation complicated by bilateral empyemas - an alternative management strategy
P Kallis FRCS J A C Chalmers FRCS A J Wood FRCS Department of Cardiothoracic Surgery, The Royal London Hospital, London El lBB Keywords: oesophageal perforation; empyema
Instrumental perforation of the oesophagus carries a high morbidity and mortality'. An interval longer than 36 h between perforation and treatment is associated with 50% mortality3. Particularly difficult to manage are oesophageal perforations associated with fistulae and suppuration following attempted repair4. We report such a case complicated by bilateral empyemas, referred to us one month after attempted repair, managed successfully using an alternative management strategy.
Case report A 66-year-old woman presented to another hospital with a 2-year history of reflux oesophagitis and dysphagia. A barium swallow revealed a hiatus hernia and a benign oesophageal stricture confirmed by multiple biopsies. During oesophagoscopic dilatation perforation was suspected.
At laparotomy perforation of the lower oesophagus was repaired, the hiatus hernia reduced and fundoplication performed. Four days later she became pyrexial and dyspnoeic. A chest radiograph revealed bilateral pleural effusions and gastrografin swallow (Figure 1) demonstrated free egress of contrast into both pleural spaces. Conservative management consisting of intercostal drainage, antibiotics and parenteral nutrition resulted in initial improvement but 4 weeks later she deterioratecl and was transferred to the London Hospital. On admission she was toxic and had bilateral pleural effusions (Figure 2). Review of all X-rays revealed complete obstruction ofthe lower oesophagus with bilateral oesophagopleural fistulae (Figure 1). Drainage of large quantities of pus was accomplished by insertion ofbilateral intercostal drains. The pleural spaces were irrigated by infusion of isotonic saline, through a naso-oesophageal tube, which drained via the intercostal drains. Two weeks later she was apyrexial and fit to undergo oesophageal bypass. At laparotomy the stomach was mobilized, the oesophagogastric junction transected and the proximal end oversewn. The cervical oesophagus was mobilized through a left cervical incision, transected and the distal end oversewn, thus isolating the thoracic oesophagus. Gastrointestnal continuity was restored by tunnelling the stomach retrsternally and performing gastro-oesophageal anastomosis in the neck. One week later the patient was eating normally. Three weeks after oesophageal bypass, oesophagectomy and decortication was performed through a right thoracotomy. The right chest drains were removed on the 5th postoperative day. The left chest drain was-gradually shortened while draining into colostomy bags and removed a month later. Two months after transfer to The London Hospital she was discharged home. Dilatation of an anastomotic stricture was required twice in the first year but she remains asymptomatic 2 years later.
41
Case presented to Clinical Section, 9 November 1990
Discussion The major prognostic factors of oesophageal perforations are: ) the interval between perforation and treatment, (ii) the anatomical site of perforation, (iii) pro-existing oesophageal obstruction, (iv) the modality of treatment, and (v) the Xexperience of the managing team4. ln this case immediate repair was attempted whereas many authors`17 recommend resectioci of the stricture and primary oesophagogastric anastomosis. Such an approach treats both perforation and stricture in one stage.
o,...A
Figure 1. Gastrografin swallow showing bilateral oesophagopleural fistulae and distal oesophageal obstruction
Correspondence to: Mr P Kallis, Department of Cardiothoracic Surgery, St- George's Hospital, London SW17 OQT
i.
Figure2. Chest radiograph showing large bilateral pleural effusions
0141-0768/92/
010041-02/$02.00/0 X) 1992 The Royal Society of Medicine
42
Journal of the Royal Society of Medicine Volume 85 January 1992
Once gross sepsis is present a two-staged procedure is favoured5-7. During the first stage the oesophagus is resected, the oesophagogastric junction closed and the thoracic cavity debrided. An end cervical oesophagostomy and a feeding gastrostomy complete the procedure. Three months later gastrointestinal continuity is restored by colonic
with meticulous planning adopting established principles as no treatment is applicable to all patients. This case demonstrates an alternative management strategy that increases the armamentarium of the team managing oesophageal perforations associated with bilateral sepsis.
interposition between the cervical oesophagus and the stomach. On transfer to our department this patient was already one month post repair and with established sepsis. We approached the problem in three stages and in the reverse order. Firstly the general condition of the patient was improved, then normal gatrointestinal function restored and finally the oesophagus resected. This approach offers several advantages by avoiding: (i) cervical oesophagostomy, (ii) feeding gastrostomy (iii) the contaminated posterior mediastinum during reconstruction and (iv) left decortication. It also establishes normal gastrointestinal function earlier and shortens the overall treatment period. Resecting the oesophagus last necessitates the presence of chest drains for longer but the morbidity is reduced by cutting the drains and allowing drainage into colostomy bags. Oesophageal perforation carries a high mortality, especially when associated with sepsis. Good results can be achieved
References 1 Craddock DR, Logan A, Myell M. Traumatic rupture of the oesophagus and stomach. Thorax 1968;23:657-62 2 Sandrasagra FA, English TAH, Milstein BB. The management and prognosis of oesophageal perforation. Br J Surg 1978; 65:629-32 3 Goldstein LA, Thompson WR. Esophageal perforations: A 15 year experience. Am J Surg 1982;143:495-503 4 Moghissi K. Instrumental perforations of the oesophagus. Br J Hosp Med 1988;March:231-6 5 Keen G. The surgical management of old oesophageal perforations. J Thorac Cardiovasc Surg 1968;56:603-6 6 Triggiani E, Belsey R. Oesophageal trauma incidence - diagnosis and management. Thorax 1977;32:241-9 7 Brewer LA, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the oesophagus. Am J Surg 1986;152;62-9
Normogastrinaemic gastric hypersecretion with recurrent and fistulating jejunal ulcer
(Accepted 14 August 1991)
Radne Lv.Lv
IO
Ow
1azo
200 mgMd
80 m/d-I.v.
20 md-oral
120 mgl - i.v.
3200
8
Case presented to Clinical Section, 9 November 1990
2800
~*2400
P Rao MB BS1 J H Baron FRCP FRCS2 G Glazer MS FRCS' Departments of 'Surgery and 2Gastroenterology, St Mary's Hospital, London W2 INY
6
E20000
1800~~~~~~~~~~~~~~~~ ~1600 41 120
_
1501
400.
100 50 0i
0
Keywords: gastric hypersecretion; normogastrinaemia; intestinal fistula; omeprazole
0 1990 -
2 -6
Jawwy
12
t8
P=
M
30
0 5
k
Figure 1. Effeetof drug treatmentii8fie4 volume and acid output
We describe a patient with chronic pancreatitis, normogastrinaemic gastric hypersecretion, and a recurrent and spontaneously fistulating jejunal ulcer which responded to intravenous but not oral ameprazole. Even after excision of the fistula, truncal vagotomy and antrectomy his gastric hypersecretion continues. Case report This 41-year-old male smoker with a long history of heavy alcohol intake first presentei in 1983 with obstructive of the pancreas. This; jaundice due to a cyst ain tb but in February resolved with conservative m 1986 he developed recurrent ouctivejandice and gastrij outflow obstruction secondary to a pancreatic pseudocyst. A gastrojejunostomy and cholecystojejunostomy with a Puestow procedure relieved his symptoms. He had no pas or family history of ulcer or endocrine disease. In November 1986 he presented with an epigastric mass due to a penetrating ulcer in the jejunum immediately adjacent to the gastrojejunostomy. The ulcer was oversewn and he remained symptom free for one year on ranitidine 150 mg twice a day. After stopping ranitidine his pains returned with further induration around the laparotomy scar due to recurrence of the ulcer just beyond the gastrojejunostomy, and he was again advised long-term ranitidine. Correspondence to: Dr J H Baron
Gastric secretion tests in 198T(when off ranitidine) showed high basal (6.2 mmol/h) and peak (73 mmol) acid outputs but normal serum gastni4{4 Fuel) ahd calcium (2.4 mmol/l). In December 1989 whilI uganitidiuebIe presented with weight loss-of 5 kgin3weekea ano-pigastric fistula discrging 800-900 ml cW kWid4 1,t *Endosopy again showed ulcerationi on"ite jejuijal aideof the gastrojejunostomy in continuity*itbthe fistula. hiiia treatment with parenteral nutrition and intravenou ifusion of ranitidine 200 mg/24 hlib sofct hion i or fistula onW ~t1Ora omeprazole 20 mg capsules day h4dnieffect & acid output because the-caples pissed""" e into the 'stula drainag ags.- Howeer, om4ze by I 4h, then intravenous infusion,' (n lh 4 40 mg/12 h), abolishe pcoinad na cmpletely inhibited acidily (pH 6.0) thre was a it increase in the voluie of fistula fluid (gre 1) On 5 February 1990 afr 1das of oazole the fistula ot my d antrectomy was excised and a tUMcal performed. Nevertheli, in Ma-y he still had normobypers (basal gastrinaemic (4 pmoW) ga 17.1 mmol/h, peak 32.1 mmol/h), and he is being kept symptom free on mainten e ranitidie 150 mg twice a day. Discussion
Spontaneoub gastrointestinal fistulae are extremely rare. The aetiology is unknown. As far back as 1797 Jacob Helm of Vienna began experiments on the persistent gastric fistula
0141-0768/92/ 010042-02/$02.00/0 © 1992 The Royal Society of Medicine
