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Repair of Complete Longitudinal EsophagealRupture With Preservation of Esophageal MotilityEric Frechette, MD, FRCS(C), Ciprian Bolca, MD, and Stefane Lebel, MD, FRCS(C)Division of Thoracic Surgery, Western University, London, Ontario, Canada, and Divisions of Thoracic Surgery and General Surgery,Laval University, Quebec City, Quebec, Canada

There is no consensus on the ideal treatment for esoph-ageal perforation and on the maximal extent of esopha-geal disruption amenable to primary repair. The effect ofextensive esophageal injury on postoperative esophagealmotility is also unknown. We report the case of a longi-tudinal iatrogenic esophageal laceration extending fromthe hypopharynx to the cardia in a morbidly obese pa-tient treated with primary repair. The patient exhibited

Accepted for publication Feb 17, 2014.

Address correspondence to Dr Frechette, Ste E2-118, London HealthSciences Center, 800 Commissioners Rd E, London, Ontario, Canada N6A5W9; e-mail: eric.frechette@lhsc.on.ca.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier

no postoperative esophageal leak or stricture and main-tained a preserved esophageal peristalsis on manometryat 3 months. An extensively lacerated esophagus can berepaired primarily while maintaining a normal post-operative function.

(Ann Thorac Surg 2014;98:1496–8)� 2014 by The Society of Thoracic Surgeons

ifferent types of esophageal perforation treatment

Dhave been proposed during the years, ranging fromsimple observation to esophagectomy and includingendoscopic approaches such as clipping and stentplacement [1]. Early diagnosis and prompt treatmenthave been associated with a better outcome [2, 3]. Whensurgery is indicated, primary repair is often preferredinstead of resection, and its indications have becomewider to include patients presenting later with moresignificant degrees of esophageal damage. However, themaximal extent of esophageal injury amenable to primaryrepair with adequate postoperative function has neverbeen clearly documented. We report a case of completelongitudinal esophageal laceration repaired primarily.

Technique

PatientA morbidly obese 30-year-old woman (body mass index,47.4 kg/m2) underwent a bariatric experimental treatmentinvolving the endoscopic insertion of a proximal gastricimplantable device. During the initial 12 months, thepatient went from a weight of 121.4 kg to 90.3 kg. Afterthis initial success, the patient noticed an increase ofappetite and started to regain weight. A partial failure ofthe device was noted during endoscopy, and the decisionto remove the intragastric implant was made. The pro-cedure was performed on this patient, who was in goodpreoperative condition and fasted overnight. The inser-tion of a 60F flexible over-tube was necessary, duringwhich some degree of resistance was noted. It waspossible to remove the device relatively easily, but the

postremoval endoscopy revealed an extensive transmuralesophageal laceration, with exposed mediastinal fat. Onlya minimal degree of bleeding was documented, andthe patient never presented any sign of hemodynamicinstability.

TechniqueAfter insertion of large-bore intravenous catheters andintubation with a double-lumen catheter, a right video-assisted thoracic surgery (VATS) was planned immedi-ately to evaluate the extent of the laceration and thepossibility of performing a primary repair. Also, if anesophagectomy had been needed, the dissection of thethoracic esophagus would have been possible throughthe VATS approach, allowing the prevention of a thora-cotomy in a morbidly obese patient. The mediastinalpleura was opened, and the azygos vein was divided. Thefindings of the mediastinal exploration included a com-plete, well-delineated, longitudinal transection of theesophagus on its entire thoracic portion, without anysignificant pleural or mediastinal spillage, contamination,or bleeding. Although completely disrupted, the esoph-agus was not presenting any sign of necrosis or devitali-zation. Because of the healthy aspect of the esophagus atthe transection margins and because the rupture wasimmediately recognized without being associated withany major mediastinal contamination, the decision toattempt a primary esophageal repair was made. Aposterolateral thoracotomy in the fifth intercostal spacewas necessary to perform a two-layer repair of thethoracic esophagus with monofilament resorbable su-tures. Two neuromuscular flaps taken from the fifth andsixth intercostal spaces were used to cover the esophagealrepair. During the thoracic esophageal mobilization, itbecame evident that the disruption was extending to thecervical and abdominal portions of the esophagus, and aleft cervical incision and laparotomy were undertaken tocomplete the esophageal closure. During thoracotomy, to

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1497Ann Thorac Surg HOW TO DO IT FRECHETTE ET AL2014;98:1496–8 REPAIR OF COMPLETE ESOPHAGEAL RUPTURE

facilitate the repair a 32F chest tube was inserted into theesophageal lumen up to the cervical esophagus, and theother end was brought into the stomach. A nasogastrictube was inserted into the chest tube lumen at the time ofchest tube insertion (Fig 1). Later, at laparotomy, a smallgastrotomy incision was created to remove the chest tubewhile maintaining the nasogastric catheter in good posi-tion. A feeding jejunostomy catheter was inserted. Thecervical exploration documented a laceration extendingup to the hypopharynx, and the primary repair could becompleted at this level.

Postoperatively, the patient did well overall but expe-rienced an intrathoracic abscess caused by Escherichia colithat was drained percutaneously under computed to-mography guidance. A barium swallow performed on the11th postoperative day revealed no evidence of esopha-geal leak (Fig 2). The patient was discharged home onpostoperative day 21. Three months after the repair, thepatient had no symptoms of dysphagia, pyrosis, odyno-phagia, or regurgitation. An esophageal manometryperformed at that time revealed preserved esophagealperistalsis waves (Fig 3).

Fig 1. Schematic representation of the use of a 32F chest tube withinserted nasogastric catheter to facilitate the primary esophagealrepair.

Fig 2. Postoperative barium swallow study performed on the 11thpostoperative day, revealing no evidence of esophageal leaks orstricture. A drainage catheter is present in the right chest.

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Comment

Perforation of the esophagus has been associated withsignificant mortality rates, and there is no globalconsensus on the most appropriate way to handle thesepatients. It is generally accepted that the treatment of thiscondition must be tailored to each patient according tothe site of perforation, its cause, and clinical details suchas delay between perforation and treatment, degree ofmediastinitis, extent of esophageal injury, concurrentmedical conditions, and hemodynamic stability [4]. Ifsurgery is indicated, primary repair has been recom-mended even for patients presenting more than 24 hoursafter the injury [2]. Resection with or without immediatereconstruction has been suggested for patients presentingwith perforations associated with a malignant or benignstricture and for patients presenting late with a significantdegree of mediastinitis.It has been proposed that esophagectomy should be

undertaken in cases of extensive esophageal laceration[5]. More specifically, the length of esophageal lacerationhas been described as an indicator for the need ofesophagectomy [6, 7]. This case, which is the most

Fig 3. Postoperative manometry confirmingthe preservation of esophageal peristalticwaves, gray panels indicating esophagealcontraction at each recording sites.

1498 HOW TO DO IT FRECHETTE ET AL Ann Thorac SurgREPAIR OF COMPLETE ESOPHAGEAL RUPTURE 2014;98:1496–8

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extensive esophageal laceration primarily repaired re-ported to date, gives arguments against esophagectomywhen then injury is recognized promptly, without asso-ciated significant mediastinitis or esophageal necrosis.This case is also an example that esophageal function canbe maintained postoperatively even in cases of extensiveinjury.

In this case, the esophageal trauma was repaired over a32F chest tube that was removed through a small gas-trotomy incision. It has been suggested to perform theesophageal repair over a bougie [8]. The advantage ofusing a chest tube is that a nasogastric catheter could beinserted through its lumen and can remain in adequateposition after its withdrawal, avoiding blind maneuvers ina freshly repaired esophagus.

In conclusion, it is possible to repair an extensiveesophageal injury and maintain a normal postoperativeesophageal function if the tissue quality is adequate and ifno significant mediastinitis is present. Accordingly, theplan of treatment should be adapted to each clinicalsituation.

References

1. Abbas G, Schuchert MJ, Pettiford BL, et al. Contemporaneousmanagement of esophageal perforation. Surgery 2009;146:749–56.

2. Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current conceptsin the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg 2011;92:209–15.

3. Vallb€ohmer D, H€olscher AH, H€olscher M, et al. Options in themanagement of esophageal perforation: analysis over a 12-year period. Dis Esophagus 2010;23:185–90.

4. Keeling WB, Miller DL, Lam GT, et al. Low mortality aftertreatment for esophageal perforation: a single-center experi-ence. Ann Thorac Surg 2010;90:1669–73.

5. Altorjay A, Kiss J, V€or€os A, Szir�anyi E. The role of esoph-agectomy in the management of esophageal perforations. AnnThorac Surg 1998;65:1433–6.

6. Eroglu A, Turkyilmaz A, Aydin Y, Yekeler E,Karaoglanoglu N. Current management of esophageal perfo-ration: 20 years experience. Dis Esophagus 2009;22:374–80.

7. Ochiai T, Hiranuma S, Takiguchi N, et al. Treatment strategyfor Boerhaave’s syndrome. Dis Esophagus 2004;17:98–103.

8. Wu JT, Mattox KL, Wall MJ Jr. Esophageal perforations: newperspectives and treatment paradigms. J Trauma 2007;63:1173–84.