THE ANNALS OF THORACIC SURGERY Journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association VOLUME 19
*
NUMBER 3
*
MARCH 1975
Esophageal Perforation An Increasing Challenge John L. Sawyers, M.D., Carl E. Lane, M.D., John H. Foster, M.D., and Rollin A. Daniel, M.D. ABSTRACT Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation. The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.
D
iagnosis and treatment of perforation of the esophagus continue to be challenging problems. T h e incidence of esophageal perforations appears to be increasing. Perforated esophagus is a surgical emergency; it is the most serious and frequently the most rapidly lethal perforation of the gastrointestinal tract. Untreated it is usually fatal. Contamination of the mediastinum with corrosive fluids, food matter, and bacteria leads to cardiorespiratory embarrassment, shock, major fluid losses, and fulminating infection. However, with prompt, aggressive surgical treatment, survival can be expected in most patients.
Clinical Material A review of 64 patients from the Vanderbilt University Medical Center constitutes this report. There were 45 male and 19 female patients ranging in age From the Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn. Presented at the Twenty-first Annual Meeting of the Southern Thoracic Surgical Association, Williamsburg, Va., Nov. 7-9, 1974. Address reprint requests to Dr. Sawyers, Nashville Metropolitan General Hospital, 72 Hermitage Ave., Nashville, Tenn. 37210.
233
SAWYERS ET AL. 22
LL
12
a
10
$
6
2
4
0
2
0
YEARS DEATHS
1935-39 194044 1945-49 I 0 3
P
PP
1
_h
ma
1950-54 1955-59 1960-M 1965.73 2
4
4
9
FIG. 1. Incidence of esophageal perforation at Vanderbilt University Medical Centerfrom 1935 to 1973. From I950 to I954 there was 1 perforation per 20,000 admissions. The incidence hm risen to I per 8,000 admissions.
from 1 1 months to 78 years. Twenty-two of these patients have been seen during the past eight years, while 42 patients were treated for esophageal perforation during the preceding thirty years [21. The incidence of esophageal perforation between 1935 and 1973 is shown in Figure 1. In the period from 1950 to 1954 there was 1 perforation per 20,000 admissions. The incidence has now risen to 1 per 8,000 admissions. The incidence of iatrogenic perforation from esophageal instrumentation has decreased, but the number of esophageal perforations from external trauma and spontaneous rupture has increased. The site of esophageal perforation is shown in Figure 2. Ten perforations occurred in the cervical region, 39 in the thoracic esophagus, and 15 in the abdominal esophagus below the diaphragm. The causes of esophageal perforation in all 64 patients are presented in Table 1. Of the 10 cervical esophageal perforations, 4 occurred during endoscopy and four were from external trauma: 3 gunshot wounds and 1 stab wound from a sharp stick of wood. Foreign bodies (a dental prosthesis and a bone) were the cause of 2 perforations. FIG. 2. Site of the 64 esophageal perforations reported in this study.
I
234
THE ANNALS OF THORACIC SURGERY
Esophageal Perforation TABLE 1. CAUSES OF ESOPHAGEAL PERFORATION IN 64 PATIENTS
Cause Cervical Endoscopy Endoscopy & dilation Gunshot wound Foreign body Stab wound Thoracic Endoscopy Dilation Foreign body Trauma Paraesophageal operation Sengstaken tube Souttar tube Spontaneous rupture Abdominal Paraesophageal operation Dilation Cantor tube Perforation of ulcer Spontaneous rupture
No. of Patients 3 1 3 2 1
10
39 16 6 3 3 3
2 1 5
8 1 1
15
2 3
Most of the 39 perforations of the thoracic esophagus were iatrogenic and followed endoscopy in 16 patients, dilation in 6, rupture secondary to a Sengstaken tube in 2, penetration of a Souttar tube in 1 , and paraesophageal surgical procedures in 3 patients (hiatus hernia repair in 2 and vagotomy in 1). Spontaneous rupture occurred in 5 patients. Blunt trauma in 2 patients and a gunshot wound in 1 patient caused esophageal perforation. Three perforations were due to foreign bodies. The major cause of the 15 abdominal esophageal perforations was paraesophageal operation. These perforations occurred during vagotomy in 6 patients and esophageal hiatus hernia repair in 2. One patient perforated his esophagus by forcefully removing his Cantor tube. One perforation occurred during dilation, and 3 resulted from spontaneous rupture. In 2 patients the perforation was thought to be secondary to an esophageal ulceration. The common signs and symptoms in relation to location of the esophageal perforation are given in Table 2. Neck pain and subcutaneous emphysema manifested by crepitus were frequent findings in cervical perforation. The most consistent symptom of thoracic perforation was chest pain, which usually occurred at the time of injury and was frequently substernal. A significant temperature elevation was the next most frequent manifestation and usually occurred within a few hours. Upper abdominal pain, which occurred in 10 patients, often seemed to confuse the diagnosis. Crepitus was present in only 8 patients, but the triad of chest pain, fever, and crepitus should establish the diagnosis of thoracic esophageal perforation. Crepitus was not present in any of our 15 patients with VOL. 19, NO. 3, MARCH, 1975
235
SAWYERS E T AL. TABLE 2. SIGNS A N D SYMPTOMS OF ESOPHAGEAL PERFORATION IN 64 PATIENTS
Finding Neck pain Chest pain Abdominal pain Dyspnea Temperature elevation Crepitus
Cervical (10 patients) 8 1
0 1 3 9
Thoracic
Abdominal
0 29 10 13 27 8
0
(39 patients) (15 patients) 2 9 1
7
0
abdominal esophageal perforation, but upper abdominal pain and fever were frequent clinical findings. Contrast roentgenographic studies with either a water-soluble medium or barium demonstrated the perforation in all but 1 of the 46 patients who had this diagnostic examination.
Results The results of treatment for esophageal perforation are shown in Table 3. Among the patients with perforation of the cervical esophagus, the 1 death occurred in a patient who was injured at the time of esophagogastroscopy. Antibiotic therapy was instituted at 36 hours, when his neck was painful and swollen. The patient died after 96 hours of laryngeal edema and extensive cellulitis. The overall mortality rate for perforation of the thoracic or abdominal esophagus was 35%. Thirty patients had suture closure and drainage with 7 deaths (23%).However, in patients who had early suture closure and drainage there was only 1 death. Suture closure without drainage and treatment by drainage alone had less satisfactory results than suture closure with drainage. The time between perforation and surgical treatment definitely influenced the outcome. The mortality rate was more than four times greater when treatment was delayed longer than 24 hours (13%vs. 56%):28 of the 32 patients who were treated within 24 hours of their injury lived, while only 10 of the 23 in whom treatment was delayed survived. TABLE 3. TREATMENT AND RESULTS IN 64 PATIENTS WITH ESOPHAGEAL PERFORATION'
Treatment Cervical perforations Drainage alone Suture & drainage Nonoperative Thoracic & abdominal perforations Suture closure & drainage Suture closure without drainage Drainage alone Nonoperative treatment
Lived
Died
Mortality (%)
2 7 0
0 0 1
0 0 100
23
7
23
2 4 3
2 4 6
50 50 66
'Three patients in whom perforation was discovered postmortem or just prior to death were not treated.
236
THE ANNALS OF THORACIC SURGERY
Esophageal Perforation
Comment Perforation of the esophagus continues to be a challenge for physicians [81. The number of cases in our institution is not decreasing, even though iatrogenic perforations from instrumentation have been fewer in recent years. However, perforations from trauma, associated paraesophageal operations, and spontaneous perforation have increased. Rea and his colleagues [6] have reported similar findings. The most difficult type of esophageal perforation to diagnose is spontaneous rupture. We have had experience with 9 such patients. The characteristic findings were cyanosis in half of our patients; subcutaneous emphysema, which was seen as early as 6 hours after esophageal rupture in 1 patient; a rigid, tender abdomen; and associated hydrothorax. The usual operative finding in spontaneous rupture of the esophagus is a linear tear, varying from 5 to 20 cm in length, on the left side of the esophagusjust above the diaphragm. The treatment is immediate thoracotomy, suture of the tear in the esophagus - in two layers if possible - using nonabsorbable suture material, removal of debris, and very wide drainage of the mediastinum and pleural cavity by a large thoracostomy tube. Antibiotics are given intravenously. A temporary gastrostomy is frequently done to permit earlier feeding and to provide a means of maintaining nutrition should the esophageal repair fail to heal. Since total parenteral alimentation became available we have not used gastrostomy in all instances. In our last 19 patients operated upon for esophageal perforation, gastrostomy was performed in 12. Total parenteral alimentation is especially useful for patients who develop prolonged drainage from an esophageal fistula. Wide mediastinal drainage and irrigation of the mediastinum and pleural cavity should be emphasized. There is a difference between spontaneous and traumatic esophageal perforation. Spontaneous rupture, usually postemetic rupture, is associated with forceful extrusion of gastricjuice throughout the mediastinal planes with resultant severe mediastinitis. Pleural outpouring of fluid in response to contamination, added to gastricjuice losses, may amount to several thousand milliliters in only a few hours with development of hypovolemic shock. Immediate intravenous fluid replacement is mandatory. Perforation of the esophagus should be treated surgically, and treatment should be instituted promptly. The only delay should be for emergency resuscitative procedures. Inevitably, the availability of antibiotics induced the utilization of conservative supportive measures and antibiotic therapy for small perforations, and this misleading approach is still used. The fact that some small perforations often can be treated successfully by conservative management is not questioned; the difficulty in classifying a perforation as small or of predicting the ultimate effects of a small perforation presents the real problem. We believe that early suture closure and drainage should be performed in all patients with esophageal perforation irrespective of the time interval following perforation. The surgeon’s judgment becomes important in managing perforations of
VOL. 19, NO. 3, MARCH, 1975
237
SAWYERS ET AL. long standing. There is little advantage to placing sutures in an esophageal wall which obviously will not hold them. Adequate drainage is essential for these patients. Urschel and co-workers [9] advocate esophageal exclusion and diversion in continuity - in addition to closure, drainage, nutritional support, and antibiotic therapy - for esophageal perforations that are diagnosed late. Their method of treatment involves placing a temporary ligature around the esophagus above the cardia to prevent gastroesophageal reflux that might interfere with healing. Adkins [ 11 advocates use of a fundic patch for treatment of late perforations in the distal esophagus. Rosoff and White [7] favor a gastric serosal buttress. Eleven of o u r patients sustained esophageal perforation from paraesophageal surgical procedures, usually vagotomy. If perforation is recognized at the time of injury, immediate suture repair will usually result in healing without complications. In an extensive review of this subject, Postlethwait and his associates [ 5 ] reported 24 esophageal perforations occurring in 4,414 vagotomies, an incidence of 0.54%. Awareness of the possibility of esophageal wall perforation several days after a paraesophageal procedure may lead to early recognition and appropriate treatment. When perforation occurs in an abnormal esophagus, it may be advantageous to perform a definitive operation for the underlying esophageal abnormality as well as to close the perforation. We have found that patients with achalasia who sustain an instrumental perforation are best treated by esophagocardiomyotomy in addition to early closure of the perforation. McKinnon and Ochsner [41 reported 2 patients who sustained esophageal rupture during pneumatic dilation. Both patients did well with immediate thoracotomy, closure of the tear, and a Heller myotomy. When perforation occurs in patients with carcinoma of the esophagus, immediate resection may give a better result than simple closure with drainage [3].
References 1. 2.
3. 4. 5.
6. 7. 8. 9.
238
Adkins, P. In discussion of H. C. Urschel and associates [9]. Foster, J. H., Jolly, P. C., Sawyers, J. L., and Daniel, R. A. Esophageal perforation: Diagnosis and treatment. Ann Surg 161:701, 1965. Ghosh, B. C., Choudhry, K. U., and Beattie, E. J., Jr. Perforation of the esophagus. Surg Gynecol Obstet 135:729, 1972. McKinnon, W. M. P., and Ochsner, J. L. Immediate closure and Heller procedure after Mosher bag rupture of the esophagus. Am J Surg 127: 115, 1974. Postlethwait, R. W., Kim, S. K., and Dillon, M. L. Esophageal complications of vagotomy. Surg Gynecol Obstet 128:481, 1969. Rea, W. J., Gallivan, G. J., Ecker, R. R., and Sugg, W. L. Traumatic esophageal perforation. Ann Thoruc Surg 14:671, 1972. Rosoff, L., Sr., and White, E. J. Perforation of the esophagus. Am J Surg 128:207, 1974. Symbas, P. N., Logan, W. D., Hatcher, C. R., and Abbott, 0. A. Factors in the successful recognition and management of esophageal perforation. South Med J 59:1090, 1966. Urschel, H. C., 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.
T H E ANNALS OF THORACIC SURGERY
*
NUMBER 3
*
MARCH 1975
Esophageal Perforation An Increasing Challenge John L. Sawyers, M.D., Carl E. Lane, M.D., John H. Foster, M.D., and Rollin A. Daniel, M.D. ABSTRACT Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation. The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.
D
iagnosis and treatment of perforation of the esophagus continue to be challenging problems. T h e incidence of esophageal perforations appears to be increasing. Perforated esophagus is a surgical emergency; it is the most serious and frequently the most rapidly lethal perforation of the gastrointestinal tract. Untreated it is usually fatal. Contamination of the mediastinum with corrosive fluids, food matter, and bacteria leads to cardiorespiratory embarrassment, shock, major fluid losses, and fulminating infection. However, with prompt, aggressive surgical treatment, survival can be expected in most patients.
Clinical Material A review of 64 patients from the Vanderbilt University Medical Center constitutes this report. There were 45 male and 19 female patients ranging in age From the Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn. Presented at the Twenty-first Annual Meeting of the Southern Thoracic Surgical Association, Williamsburg, Va., Nov. 7-9, 1974. Address reprint requests to Dr. Sawyers, Nashville Metropolitan General Hospital, 72 Hermitage Ave., Nashville, Tenn. 37210.
233
SAWYERS ET AL. 22
LL
12
a
10
$
6
2
4
0
2
0
YEARS DEATHS
1935-39 194044 1945-49 I 0 3
P
PP
1
_h
ma
1950-54 1955-59 1960-M 1965.73 2
4
4
9
FIG. 1. Incidence of esophageal perforation at Vanderbilt University Medical Centerfrom 1935 to 1973. From I950 to I954 there was 1 perforation per 20,000 admissions. The incidence hm risen to I per 8,000 admissions.
from 1 1 months to 78 years. Twenty-two of these patients have been seen during the past eight years, while 42 patients were treated for esophageal perforation during the preceding thirty years [21. The incidence of esophageal perforation between 1935 and 1973 is shown in Figure 1. In the period from 1950 to 1954 there was 1 perforation per 20,000 admissions. The incidence has now risen to 1 per 8,000 admissions. The incidence of iatrogenic perforation from esophageal instrumentation has decreased, but the number of esophageal perforations from external trauma and spontaneous rupture has increased. The site of esophageal perforation is shown in Figure 2. Ten perforations occurred in the cervical region, 39 in the thoracic esophagus, and 15 in the abdominal esophagus below the diaphragm. The causes of esophageal perforation in all 64 patients are presented in Table 1. Of the 10 cervical esophageal perforations, 4 occurred during endoscopy and four were from external trauma: 3 gunshot wounds and 1 stab wound from a sharp stick of wood. Foreign bodies (a dental prosthesis and a bone) were the cause of 2 perforations. FIG. 2. Site of the 64 esophageal perforations reported in this study.
I
234
THE ANNALS OF THORACIC SURGERY
Esophageal Perforation TABLE 1. CAUSES OF ESOPHAGEAL PERFORATION IN 64 PATIENTS
Cause Cervical Endoscopy Endoscopy & dilation Gunshot wound Foreign body Stab wound Thoracic Endoscopy Dilation Foreign body Trauma Paraesophageal operation Sengstaken tube Souttar tube Spontaneous rupture Abdominal Paraesophageal operation Dilation Cantor tube Perforation of ulcer Spontaneous rupture
No. of Patients 3 1 3 2 1
10
39 16 6 3 3 3
2 1 5
8 1 1
15
2 3
Most of the 39 perforations of the thoracic esophagus were iatrogenic and followed endoscopy in 16 patients, dilation in 6, rupture secondary to a Sengstaken tube in 2, penetration of a Souttar tube in 1 , and paraesophageal surgical procedures in 3 patients (hiatus hernia repair in 2 and vagotomy in 1). Spontaneous rupture occurred in 5 patients. Blunt trauma in 2 patients and a gunshot wound in 1 patient caused esophageal perforation. Three perforations were due to foreign bodies. The major cause of the 15 abdominal esophageal perforations was paraesophageal operation. These perforations occurred during vagotomy in 6 patients and esophageal hiatus hernia repair in 2. One patient perforated his esophagus by forcefully removing his Cantor tube. One perforation occurred during dilation, and 3 resulted from spontaneous rupture. In 2 patients the perforation was thought to be secondary to an esophageal ulceration. The common signs and symptoms in relation to location of the esophageal perforation are given in Table 2. Neck pain and subcutaneous emphysema manifested by crepitus were frequent findings in cervical perforation. The most consistent symptom of thoracic perforation was chest pain, which usually occurred at the time of injury and was frequently substernal. A significant temperature elevation was the next most frequent manifestation and usually occurred within a few hours. Upper abdominal pain, which occurred in 10 patients, often seemed to confuse the diagnosis. Crepitus was present in only 8 patients, but the triad of chest pain, fever, and crepitus should establish the diagnosis of thoracic esophageal perforation. Crepitus was not present in any of our 15 patients with VOL. 19, NO. 3, MARCH, 1975
235
SAWYERS E T AL. TABLE 2. SIGNS A N D SYMPTOMS OF ESOPHAGEAL PERFORATION IN 64 PATIENTS
Finding Neck pain Chest pain Abdominal pain Dyspnea Temperature elevation Crepitus
Cervical (10 patients) 8 1
0 1 3 9
Thoracic
Abdominal
0 29 10 13 27 8
0
(39 patients) (15 patients) 2 9 1
7
0
abdominal esophageal perforation, but upper abdominal pain and fever were frequent clinical findings. Contrast roentgenographic studies with either a water-soluble medium or barium demonstrated the perforation in all but 1 of the 46 patients who had this diagnostic examination.
Results The results of treatment for esophageal perforation are shown in Table 3. Among the patients with perforation of the cervical esophagus, the 1 death occurred in a patient who was injured at the time of esophagogastroscopy. Antibiotic therapy was instituted at 36 hours, when his neck was painful and swollen. The patient died after 96 hours of laryngeal edema and extensive cellulitis. The overall mortality rate for perforation of the thoracic or abdominal esophagus was 35%. Thirty patients had suture closure and drainage with 7 deaths (23%).However, in patients who had early suture closure and drainage there was only 1 death. Suture closure without drainage and treatment by drainage alone had less satisfactory results than suture closure with drainage. The time between perforation and surgical treatment definitely influenced the outcome. The mortality rate was more than four times greater when treatment was delayed longer than 24 hours (13%vs. 56%):28 of the 32 patients who were treated within 24 hours of their injury lived, while only 10 of the 23 in whom treatment was delayed survived. TABLE 3. TREATMENT AND RESULTS IN 64 PATIENTS WITH ESOPHAGEAL PERFORATION'
Treatment Cervical perforations Drainage alone Suture & drainage Nonoperative Thoracic & abdominal perforations Suture closure & drainage Suture closure without drainage Drainage alone Nonoperative treatment
Lived
Died
Mortality (%)
2 7 0
0 0 1
0 0 100
23
7
23
2 4 3
2 4 6
50 50 66
'Three patients in whom perforation was discovered postmortem or just prior to death were not treated.
236
THE ANNALS OF THORACIC SURGERY
Esophageal Perforation
Comment Perforation of the esophagus continues to be a challenge for physicians [81. The number of cases in our institution is not decreasing, even though iatrogenic perforations from instrumentation have been fewer in recent years. However, perforations from trauma, associated paraesophageal operations, and spontaneous perforation have increased. Rea and his colleagues [6] have reported similar findings. The most difficult type of esophageal perforation to diagnose is spontaneous rupture. We have had experience with 9 such patients. The characteristic findings were cyanosis in half of our patients; subcutaneous emphysema, which was seen as early as 6 hours after esophageal rupture in 1 patient; a rigid, tender abdomen; and associated hydrothorax. The usual operative finding in spontaneous rupture of the esophagus is a linear tear, varying from 5 to 20 cm in length, on the left side of the esophagusjust above the diaphragm. The treatment is immediate thoracotomy, suture of the tear in the esophagus - in two layers if possible - using nonabsorbable suture material, removal of debris, and very wide drainage of the mediastinum and pleural cavity by a large thoracostomy tube. Antibiotics are given intravenously. A temporary gastrostomy is frequently done to permit earlier feeding and to provide a means of maintaining nutrition should the esophageal repair fail to heal. Since total parenteral alimentation became available we have not used gastrostomy in all instances. In our last 19 patients operated upon for esophageal perforation, gastrostomy was performed in 12. Total parenteral alimentation is especially useful for patients who develop prolonged drainage from an esophageal fistula. Wide mediastinal drainage and irrigation of the mediastinum and pleural cavity should be emphasized. There is a difference between spontaneous and traumatic esophageal perforation. Spontaneous rupture, usually postemetic rupture, is associated with forceful extrusion of gastricjuice throughout the mediastinal planes with resultant severe mediastinitis. Pleural outpouring of fluid in response to contamination, added to gastricjuice losses, may amount to several thousand milliliters in only a few hours with development of hypovolemic shock. Immediate intravenous fluid replacement is mandatory. Perforation of the esophagus should be treated surgically, and treatment should be instituted promptly. The only delay should be for emergency resuscitative procedures. Inevitably, the availability of antibiotics induced the utilization of conservative supportive measures and antibiotic therapy for small perforations, and this misleading approach is still used. The fact that some small perforations often can be treated successfully by conservative management is not questioned; the difficulty in classifying a perforation as small or of predicting the ultimate effects of a small perforation presents the real problem. We believe that early suture closure and drainage should be performed in all patients with esophageal perforation irrespective of the time interval following perforation. The surgeon’s judgment becomes important in managing perforations of
VOL. 19, NO. 3, MARCH, 1975
237
SAWYERS ET AL. long standing. There is little advantage to placing sutures in an esophageal wall which obviously will not hold them. Adequate drainage is essential for these patients. Urschel and co-workers [9] advocate esophageal exclusion and diversion in continuity - in addition to closure, drainage, nutritional support, and antibiotic therapy - for esophageal perforations that are diagnosed late. Their method of treatment involves placing a temporary ligature around the esophagus above the cardia to prevent gastroesophageal reflux that might interfere with healing. Adkins [ 11 advocates use of a fundic patch for treatment of late perforations in the distal esophagus. Rosoff and White [7] favor a gastric serosal buttress. Eleven of o u r patients sustained esophageal perforation from paraesophageal surgical procedures, usually vagotomy. If perforation is recognized at the time of injury, immediate suture repair will usually result in healing without complications. In an extensive review of this subject, Postlethwait and his associates [ 5 ] reported 24 esophageal perforations occurring in 4,414 vagotomies, an incidence of 0.54%. Awareness of the possibility of esophageal wall perforation several days after a paraesophageal procedure may lead to early recognition and appropriate treatment. When perforation occurs in an abnormal esophagus, it may be advantageous to perform a definitive operation for the underlying esophageal abnormality as well as to close the perforation. We have found that patients with achalasia who sustain an instrumental perforation are best treated by esophagocardiomyotomy in addition to early closure of the perforation. McKinnon and Ochsner [41 reported 2 patients who sustained esophageal rupture during pneumatic dilation. Both patients did well with immediate thoracotomy, closure of the tear, and a Heller myotomy. When perforation occurs in patients with carcinoma of the esophagus, immediate resection may give a better result than simple closure with drainage [3].
References 1. 2.
3. 4. 5.
6. 7. 8. 9.
238
Adkins, P. In discussion of H. C. Urschel and associates [9]. Foster, J. H., Jolly, P. C., Sawyers, J. L., and Daniel, R. A. Esophageal perforation: Diagnosis and treatment. Ann Surg 161:701, 1965. Ghosh, B. C., Choudhry, K. U., and Beattie, E. J., Jr. Perforation of the esophagus. Surg Gynecol Obstet 135:729, 1972. McKinnon, W. M. P., and Ochsner, J. L. Immediate closure and Heller procedure after Mosher bag rupture of the esophagus. Am J Surg 127: 115, 1974. Postlethwait, R. W., Kim, S. K., and Dillon, M. L. Esophageal complications of vagotomy. Surg Gynecol Obstet 128:481, 1969. Rea, W. J., Gallivan, G. J., Ecker, R. R., and Sugg, W. L. Traumatic esophageal perforation. Ann Thoruc Surg 14:671, 1972. Rosoff, L., Sr., and White, E. J. Perforation of the esophagus. Am J Surg 128:207, 1974. Symbas, P. N., Logan, W. D., Hatcher, C. R., and Abbott, 0. A. Factors in the successful recognition and management of esophageal perforation. South Med J 59:1090, 1966. Urschel, H. C., 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.
T H E ANNALS OF THORACIC SURGERY
