Modified T-Tube Repair of Delayed Esophageal Perforation Results in a Low Mortality Rate Similar to That Seen With Acute Perforations

doi:10.1016/j.athoracsur.2006.11.012

The Annals of Thoracic Surgery

Volume 83, Issue 3, March 2007, Pages 1129-1133

https://doi.org/10.1016/j.athoracsur.2006.11.012 Get rights and content

Background

Esophageal perforation carries a high mortality and morbidity rate, especially if treatment is delayed more than 24 hours. We present a large series of patients requiring operative treatment of esophageal perforations with attention to an infrequently used method of dealing with delayed intrathoracic perforations.

Methods

All patients undergoing operative treatment for intrathoracic esophageal perforation at the Brigham and Women’s hospital between 1989 and 2003 were reviewed. Mortality, morbidity, length of stay, nature of esophageal injury, type of repair, and outcome were reviewed.

Results

Forty-three operations for perforation of the thoracic esophagus were performed. Overall 30-day or in-hospital mortality was 7.0%, and overall morbidity was 47%. Most acute thoracic esophageal perforations were treated with primary repair and had a mortality rate of 5%, whereas most delayed perforations were treated with T-tube repair and had a mortality rate of 8.7%. The complication rate in the group repaired within 24 hours was 20%, whereas it was 61% in the group repaired after 24 hours. The complication rate in the group repaired within 72 hours was 42%, and it was 82% in the group repaired after 72 hours.

Conclusions

Treatment of delayed (more than 24 hours) thoracic esophageal perforations with a controlled fistula through T-tube results in a very low mortality similar to that seen with acute perforations (less than 24 hours). Morbidity and length of stay remain high. Delay in treatment of intrathoracic esophageal perforations beyond 24 and 72 hours results in a doubling of morbidity at each interval.

Section snippets

Material and Methods

The Department of Surgery operative database at Brigham and Women’s Hospital was queried for all operations performed between 1989 and 2003 carrying the International Classification of Diseases (ICD-9) diagnosis of esophageal perforation (530.4). Cervical and intra-abdominal perforations were excluded. Only patients with perforations of the native esophagus were included. Patients found to have leaks secondary to esophageal resection with anastomosis were excluded. Gastric leaks into the chest

Results

Between 1989 and 2003, 43 patients underwent operative treatment of perforations of the thoracic esophagus. There were three 30-day or in-hospital deaths, for an overall mortality of 7.0%. Twenty of the patients (47%) had one or more complication. Further analysis of etiology, interventions, and outcome are made according to region of perforation.

Comment

Primary repair of acute (less than 24 hours) esophageal perforations is the preferred therapy and is associated with a low incidence of leak and a mortality rate of approximately 10% in the current literature [9]. Most papers describe a dramatic increase in perioperative mortality for perforations repaired beyond 24 hours with a mortality rate approaching 30% to 40% [1, 2, 3, 9]. Patients with delayed presentation of thoracic esophageal perforations present unique challenges. These patients are

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Esophageal perforations occur infrequently and may produce vague symptoms leading to diagnostic and therapeutic delays. High index of suspicion particularly in penetrating chest trauma followed by relevant investigations may reduce delay. Principles of management include treatment of contamination, wide local drainage, source control and nutritional support. Source control is achieved surgically or through endoluminal placement of stents. Surgical options include primary repair, creation of a controlled fistula by T-tube or esophageal exclusion.
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Perforation of the esophagus is a potentially serious and life-threatening medical emergency. Given the diverse etiologies and wide variety in clinical presentations of the perforated esophagus, the managing physician must possess a thorough understanding of the principles behind its treatment, as well as have access to an array of therapeutic tools, to provide an optimal outcome. Surgical therapy has occupied a prominent place in the management armamentarium of esophageal perforation since Norman Barrett reported the first case of successful primary repair in 1946. Over the subsequent decades, surgical techniques have been developed and refined, and improvements in antibiotics, critical care, radiologic imaging, and percutaneous interventions have evolved. More recently, nonoperative and endoscopic approaches have been introduced as alternatives to surgery in appropriately selected patients, further improving the ability to treat this condition. Despite these advances, the morbidity and mortality following perforation of the esophagus remain high, especially in cases of diagnostic delay, underscoring the importance of prompt recognition and appropriate treatment of this malady. Therefore considerable clinical judgment is required on the part of the managing physician because treatment decisions may have a major impact on outcomes.
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Traumatic esophageal injuries occur less than 10% of the time in the setting of blunt or penetrating trauma. The purpose of this literature review is to provide an update on the most recent changes involving the diagnosis and treatment of esophageal injuries. A literature search was conducted using PubMed, to identify articles written in English language with the terms “non- iatrogenic”, “esophageal”, “trauma”, “diagnosis”, “management”, and “prognosis”. Case reports and articles involving non-traumatic esophageal perforations were excluded. Fifty pertinent articles in English language from 1947 to 2015 were selected for review. Based on the review of all articles, we designed a diagnostic and therapeutic algorithm to facilitate the diagnosis and management of the traumatic esophageal injury.
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Penetrating oesophageal injuries are extremely rare. Their timely recognition can be difficult and optimal treatment remains controversial. Early recognition of injury is possible with the help of a high index of suspicion and early radiological and endoscopic examinations. Prompt surgical intervention with primary repair of injury, should be the goal.
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T-tube placement though oesophageal defects can prove to be an effective treatment option to repair both iatrogenic and penetrating injuries of the Oesophagus, whether early or delayed.

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Original articleGeneral thoracicModified T-Tube Repair of Delayed Esophageal Perforation Results in a Low Mortality Rate Similar to That Seen With Acute Perforations

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Ann Thorac Surg

Am J Surg

Ann Thorac Surg

Am J Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Original article
General thoracic
Modified T-Tube Repair of Delayed Esophageal Perforation Results in a Low Mortality Rate Similar to That Seen With Acute Perforations