EDITORIALS Management of Esophageal Perforation
P
erforation is one of the few life-threatening surgical emergencies affecting the esophagus. Yet, despite general awareness of the severity of the problem, early diagnosis and treatment are not uniformly achieved and therapeutic efforts all too often prove ineffective. The goals of treatment -to provide adequate drainage of soiled tissue spaces and to prevent continued contamination -are misleadingly simple. The site, size, age, and cause of the perforation, the amount and quality of leakage, the tissue response, and the presence of distal obstruction or preexisting esophageal disease all influence the effectiveness of treatment. Thoracic esophageal perforations are notoriously difficult to manage, especially when seen late; even under seemingly ideal circumstances, the repair may break down and lead to fatal sepsis. The report by Grillo and Wilkins in this issue of The Annals (p 387) on the use of an encircling pedicled pleural flap to buttress or augment late surgical repair of perforations of the thoracic esophagus is a welcome addition to the surgical repertoire. This simple, direct patch technique has considerable appeal. Unlike other patch procedures that employ gastric [8, 101, diaphragmatic [7], or pericardial [5] tissue, the creation of a pleural pedicle does not require entry into (and potential contamination of) unaffected body cavities. Indeed, as noted by the authors, the inflammatory reaction to perforation thickens and toughens the parietal pleura so that it is particularly suitable for the task at hand. Further, the pleural pedicle can be developed with greater facility than can any other graft (even the intercostal pedicle) [l]. Finally, the method has particular appeal because it does not entail major distortion of normal anatomy. With proper healing, esophageal function can be resumed without prolonged disability or additional surgical intervention. While we applaud the addition of this simple, effective technique, a word of caution is in order. Almost all reports dealing with the management of esophageal perforation are anecdotal - case reports. These injuries occur so infrequently and under such varied circumstances that few surgeons or institutions have sufficient experience to report more than a small number of cases treated by any single method. In addition, the case reports that do appear in the literature often reflect surgical successes or the development of new techniques that seem to have altered a previously gloomy experience with the problem. The treatment dilemma is further attested to by the sheer multitude of techniques available for the management of thoracic esophageal perforations [3, 61. It is, of course, impossible to write a simple surgical prescription applicable to all esophageal perforations, even of a given variety. It is, however, essential that 486
THE ANNALS OF THORACIC SURGERY
Editorial each surgeon called upon to deal with these problems have a clear and concise working understanding of the clinical problems and the rational application of the multiple surgical techniques currently available. In their discussion, Grillo and Wilkins provide a useful updated outline for management, emphasizing minimal anatomical and functional disturbance of the esophagus. However, until their favorable experience and the partial exclusion and diversion technique of Urschel and colleagues [91 or of Menguy [4]are confirmed, total esophageal exclusion, as suggested by Johnson, Schwegman, and Kirby [2],should continue to be considered as good rescue for selected desperately ill patients with late perforations and for those in whom conservative treatment has failed. There has been considerable reluctance in the past to employ such measures, largely because surviving patients require extensive reconstruction. However, in the past, conventional repair has been associated with a mortality in excess of 60% in patients treated more than 18 hours after perforation. While seemingly radical operations may still prove to be the conservative choice, new techniques deserve full exploration. It is hoped that surgeons will be encouraged in the future to report their failures as well as successes and that editors will be inclined to publish these anecdotes. Perhaps it is even time for a registry in which all our experiences could be assembled and useful conclusions drawn. W. SPENCER PAYNE, M.D. Department of Surgery Mayo Clinic and Foundation Rochester, Minn. 55901
References 1. Dooling, J. A., and Zick, H. R. Closure of an esophagopleural fistula using onlay intercostal pedicle graft. Ann Thorac Surg 3:553, 1967. 2. Johnson, J., Schwegman, C. W., and Kirby, C. K. Esophageal exclusion for persistent fistula following spontaneous rupture of the esophagus. J Thorac Cardiovmc Surg 32:827, 1956. 3. Loop, F. D., and Groves, L. K. Esophageal perforations. Ann Thorax Surg 10:571, 1970. 4. Menguy, R. Near-total esophageal exclusion by cervical esophagostomy and tube gastrostomy in the management of massive esophageal perforation: Report of a case. Ann Surg 173:613, 1971. 5. Millard, A. H. “Spontaneous”perforation of the oesophagus treated by utilization of a pericardial flap. Br J Surg 58:70,1971. 6. Payne, W. S., Brown, P. W., Jr., and Fontana, R. S. Esophageal Perforation, Mallory-WeissSyndrome, and Acquired Esophageal Fistulas. In W. S. Payne and A. M. Olsen (Eds), The Esophagus. Philadelphia: Lea & Febiger, 1974. Pp 171 - 189. 7. Rao, K. V. S., Mir, M., and Cogbill, C. L. Management of perforations of the thoracic esophagus: A new technic utilizing a pedicle flap of diaphragm. Am J Surg 127:609, 1974. 8. Thal, A. P., and Hatafuku, T. Improved operation for esophageal rupture. JAMA 188:826, 1964. 9. Urschel, H. C.,Jr., Razzuk, M. A., Wood, R. E., Galbraith, N., Pockey, M., and Paulson, D. L. Improved management of esophageal perforation: Exclusion and diversion in continuity. Ann Surg 179:587, 1974. 10. Woodward, E. R. Discussion of A. P. Thal, A unified approach to surgical problems of the esophagogastric junction. Ann Surg 168:542, 1968. VOL. 20, NO. 4, OCTOBER, 1975
487
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erforation is one of the few life-threatening surgical emergencies affecting the esophagus. Yet, despite general awareness of the severity of the problem, early diagnosis and treatment are not uniformly achieved and therapeutic efforts all too often prove ineffective. The goals of treatment -to provide adequate drainage of soiled tissue spaces and to prevent continued contamination -are misleadingly simple. The site, size, age, and cause of the perforation, the amount and quality of leakage, the tissue response, and the presence of distal obstruction or preexisting esophageal disease all influence the effectiveness of treatment. Thoracic esophageal perforations are notoriously difficult to manage, especially when seen late; even under seemingly ideal circumstances, the repair may break down and lead to fatal sepsis. The report by Grillo and Wilkins in this issue of The Annals (p 387) on the use of an encircling pedicled pleural flap to buttress or augment late surgical repair of perforations of the thoracic esophagus is a welcome addition to the surgical repertoire. This simple, direct patch technique has considerable appeal. Unlike other patch procedures that employ gastric [8, 101, diaphragmatic [7], or pericardial [5] tissue, the creation of a pleural pedicle does not require entry into (and potential contamination of) unaffected body cavities. Indeed, as noted by the authors, the inflammatory reaction to perforation thickens and toughens the parietal pleura so that it is particularly suitable for the task at hand. Further, the pleural pedicle can be developed with greater facility than can any other graft (even the intercostal pedicle) [l]. Finally, the method has particular appeal because it does not entail major distortion of normal anatomy. With proper healing, esophageal function can be resumed without prolonged disability or additional surgical intervention. While we applaud the addition of this simple, effective technique, a word of caution is in order. Almost all reports dealing with the management of esophageal perforation are anecdotal - case reports. These injuries occur so infrequently and under such varied circumstances that few surgeons or institutions have sufficient experience to report more than a small number of cases treated by any single method. In addition, the case reports that do appear in the literature often reflect surgical successes or the development of new techniques that seem to have altered a previously gloomy experience with the problem. The treatment dilemma is further attested to by the sheer multitude of techniques available for the management of thoracic esophageal perforations [3, 61. It is, of course, impossible to write a simple surgical prescription applicable to all esophageal perforations, even of a given variety. It is, however, essential that 486
THE ANNALS OF THORACIC SURGERY
Editorial each surgeon called upon to deal with these problems have a clear and concise working understanding of the clinical problems and the rational application of the multiple surgical techniques currently available. In their discussion, Grillo and Wilkins provide a useful updated outline for management, emphasizing minimal anatomical and functional disturbance of the esophagus. However, until their favorable experience and the partial exclusion and diversion technique of Urschel and colleagues [91 or of Menguy [4]are confirmed, total esophageal exclusion, as suggested by Johnson, Schwegman, and Kirby [2],should continue to be considered as good rescue for selected desperately ill patients with late perforations and for those in whom conservative treatment has failed. There has been considerable reluctance in the past to employ such measures, largely because surviving patients require extensive reconstruction. However, in the past, conventional repair has been associated with a mortality in excess of 60% in patients treated more than 18 hours after perforation. While seemingly radical operations may still prove to be the conservative choice, new techniques deserve full exploration. It is hoped that surgeons will be encouraged in the future to report their failures as well as successes and that editors will be inclined to publish these anecdotes. Perhaps it is even time for a registry in which all our experiences could be assembled and useful conclusions drawn. W. SPENCER PAYNE, M.D. Department of Surgery Mayo Clinic and Foundation Rochester, Minn. 55901
References 1. Dooling, J. A., and Zick, H. R. Closure of an esophagopleural fistula using onlay intercostal pedicle graft. Ann Thorac Surg 3:553, 1967. 2. Johnson, J., Schwegman, C. W., and Kirby, C. K. Esophageal exclusion for persistent fistula following spontaneous rupture of the esophagus. J Thorac Cardiovmc Surg 32:827, 1956. 3. Loop, F. D., and Groves, L. K. Esophageal perforations. Ann Thorax Surg 10:571, 1970. 4. Menguy, R. Near-total esophageal exclusion by cervical esophagostomy and tube gastrostomy in the management of massive esophageal perforation: Report of a case. Ann Surg 173:613, 1971. 5. Millard, A. H. “Spontaneous”perforation of the oesophagus treated by utilization of a pericardial flap. Br J Surg 58:70,1971. 6. Payne, W. S., Brown, P. W., Jr., and Fontana, R. S. Esophageal Perforation, Mallory-WeissSyndrome, and Acquired Esophageal Fistulas. In W. S. Payne and A. M. Olsen (Eds), The Esophagus. Philadelphia: Lea & Febiger, 1974. Pp 171 - 189. 7. Rao, K. V. S., Mir, M., and Cogbill, C. L. Management of perforations of the thoracic esophagus: A new technic utilizing a pedicle flap of diaphragm. Am J Surg 127:609, 1974. 8. Thal, A. P., and Hatafuku, T. Improved operation for esophageal rupture. JAMA 188:826, 1964. 9. Urschel, H. C.,Jr., Razzuk, M. A., Wood, R. E., Galbraith, N., Pockey, M., and Paulson, D. L. Improved management of esophageal perforation: Exclusion and diversion in continuity. Ann Surg 179:587, 1974. 10. Woodward, E. R. Discussion of A. P. Thal, A unified approach to surgical problems of the esophagogastric junction. Ann Surg 168:542, 1968. VOL. 20, NO. 4, OCTOBER, 1975
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