with Distal Obstruction

Transcription

1 Definitive Surgery for the Treatment of Esophageal Perforation with Distal Obstruction Gerard A. Kaiser, M.D., Frederick 0. Bowman, Jr., M.D., and Robert H. Wylie, M.D. T he treatment usually advocated for intrathoracic perforation of the esophagus is surgical repair of the damage and drainage of the pleura and mediastinum, if the diagnosis is made within 10 to 12 hours of the accident [3, 10, 121. In the past, little distinction has been made between obstructed and unobstructed cases. The criteria for surgical treatment and success were related to the time elapsed before proper treatment was instituted and the site of the perforation, its size, and the method of injury, rather than the underlying pathology. Although they may be faced with distal obstruction that will prevent a fistula from closing and often makes repair of the fistula impossible, some thoracic surgeons feel that definitive surgery to relieve the obstruction is too hazardous to be undertaken at that time [81. It was not until Groves analyzed the results with respect to the underlying pathology and reported on primary esophageal resection for obstruction that further impetus for such surgical intervention occurred [41. Kerr reviewed the salient features of the 19 reported cases of esophagogastrectomy for the treatment of perforation with distal obstruction and added 3 successful cases [71. Johnson recently reported six early esophagogastrostomies for iatrogenic perforation of the esophagus with distal obstruction and advocated this therapy if the operation is undertaken six to eight hours following injury 161. After noting in detail 3 cases of esophageal perforation with distal obstruction treated with definitive surgery, we attempt in the present report to place this form of therapy in proper perspective in relation to a larger series of esophageal perforations. From the Department of Surgery, College of Physicians and Surgeons, and the Surgical Service, Columbia Presbyterian Hospital, New York, N.Y. Presented at the Fifth Annual Meeting of The Society of Thoracic Surgeons, San Diego, Calif., Jan , Address reprint requests to Dr. Kaiser, 622 West 168th St., New York, N.Y VOL. 8, NO. I, JULY,

2 KAISER, BOWMAN, AND WYLIE CASE REPORTS CASE 1 C. F., a 76-year-old female, was admitted on April 28, 1964, with a chief complaint of nine months of increasing dysphagia. The patient had been limited to a full fluid diet, and during the two months prior to admission she had lost 30 pounds. Esophagogram performed at the time of admission revealed a constriction of the lower third of the esophagus. Physical Examination. The patient was a frail, cachectic female in no acute distress, with pulse rate of 84 and blood pressure of 140/80. Small palpable nodes were found within the left supraclavicular fossa. The remainder of the examination was unrevealing except for tenderness in the epigastrium and a palpable liver edge. Hospital Course. On the day after admission, esophagoscopy was performed while the patient was under general anesthesia. An exophytic lesion was found 38 cm. from the level of the incisors, and a biopsy specimen was taken. On the evening of operation, the patient suddenly complained of severe steady upper abdominal and subxiphoid pain. A chest roentgenogram at that time revealed a small pneumomediastinum with increasing left pleural effusion. The leukocyte count rose to 16,500 cells. The patient was immediately given antibiotics and fluids intravenously, and within 10 hours she was taken to the operating room, where an emergency esophagogastrectomy was performed via a thoracic approach. At operation an esophageal tumor was present, which was subsequently shown to be squamous in cell type. Metastases were found within lymph nodes in the mediastinum and were palpable within the liver. There was marked edema and inflammation of the mediastinum, a left pleural effusion, and evidence of perforation just proximal to the tumor. The distal one-third of the esophagus and proximal one-half of the stomach were resected. Postoperatively, a regimen of continued antibiotic coverage was prescribed, with penicillin and streptomycin given intravenously. The patient s chest tube was removed on the third postoperative day, and clear fluids were given and well tolerated on the seventh postoperative day, following a barium swallow that revealed no anastomotic leak. At the time of discharge, a chest roentgenogram revealed marked resolution of the left pleural effusion. The patient was placed on a soft diet and transferred to a nursing home. She did well in the nursing home for approximately one month. She was then readmitted to the hospital and experienced a progressive downhill course. She died in July, 1964, seven weeks postoperatively. CASE 2 W. S., a 73-year-old male, was admitted on July 10, 1967, with a three-month history of progressive dysphagia. This was accompanied by marked anorexia and a 30-pound weight loss, as well as substernal pain radiating to the right upper quadrant. Physical Examination. This revealed bilateral cataracts. There were no palpable nodes in the supraclavicular area, and no other significant findings. Laboratory Data. Hematocrit value was 20% and leukocyte count, 6,250 cells. Electrolytes were within normal limits. Blood urea nitrogen level was 49; prothrombin time, 15 seconds; and alkaline phosphatase level, 9. Bilirubin and hepatic enzyme studies were within normal limits. Hospital Course. On July 11, 1967, cineesophagograms were performed and interpreted as revealing a carcinoma of the distal esophagus or proximal stomach and incidental Zenker s diverticulum. Esophagoscopy on July 12, 1967, revealed foreign material in the esophagus, but no mass lesion was noted. Biopsy of the esophagogastric junction revealed only thickened squamous epithelium, with no evidence of malignancy. Repeat upper gastrointestinal series on July 17, 1967, revealed a total obstruction of the distal esophagus, and in an attempt to obtain 76 THE ANNALS OF THORACIC SURGERY

3 Esophageal Perforation with Distal 0 bstruction tissue diagnosis, esophagoscopy was performed on July 18, No mass lesion was found; multiple biopsy specimens were taken. Over the next 36 hours the patient developed progressive evidence of esophageal perforation, with temperature of 104", chest and back pain, pneumomediastinum evident on x-ray, and extravasation of contrast material shown on emergency esophagogram. On the advice of the chest surgical service, the patient was transfused to correct his anemia and was given antibiotics intravenously. Emergency esophagogastrectomy was performed. At the time of operation there was esophageal rupture, severe mediastinitis with left pleural effusion, and a large gastric carcinoma arising in the fundus and extending along the lesser curvature with metastases to mediastinal and ciliac lymph nodes and to the liver. The proximal half of the stomach and distal third of the esophagus and spleen were removed, and a primary esophagogastric anastomosis was performed, end of esophagus to anterior wall of gastric remnant. A chest tube was placed in the left hemithorax, and drains were placed in the left upper quadrant. A continued regimen of penicillin, chloromycetin, and streptomycin was prescribed. The chest tube was removed on the ninth postoperative day and the drains in the left upper quadrant were gradually advanced and finally removed on the sixteenth postoperative day. The patient became afebrile. A chest roentgenogram revealed progressive clearing of the left pleural effusion. Postoperative gastrointestinal series revealed intact anastomoses, and the patient was put on a soft diet and discharged. He was first in a nursing home, then at home, and was able to tolerate a soft diet without any discomfort. He did, however, experience gradual weight loss-from 112 to 104 pounds. He was readmitted to the hospital four months postoperatively on November 7, 1967, with evidence of upper gastrointestinal obstruction. X-ray studies at the time revealed extrinsic pressure on the gastric remnant, at the pylorus, apparently caused by enlarged celiac nodes and hepatic metastases, which had been present at the earlier operation. The patient experienced a gradual downhill course, and died in late December, CASE 3 D. B., a 64-year-old Negro female, had a history of progressive dysphagia for six months prior to admission on September 1, One week prior to admission the patient had experienced extension of her symptoms and she was unable to take either solid or liquid foods. During this period she lost 25 pounds. A cineesophagogram revealed a 3-cm. stricture in the region of the esophagogastric junction, which was believed from x-ray evidence to be benign. Physical Examination. On admission, physical examination revealed no palpable lymph nodes in the neck. Lung fields were clear, and there were no other abnormal findings. Laboratory Data. Hemoglobin level was 11 gm. Leukocyte count was 4,600 cells, with normal differential. Electrolytes were within normal limits. Blood urea nitrogen level was 10. Hospital Course. On September 2, 1967, the patient underwent esophagoscopy under general anesthesia, with dilatation of the distal esophagus and biopsy. There was narrowing of the lumen at 32 cm., with intact mucosa and no masses noted. Upon awakening from anesthesia she complained of nausea and severe substernal chest pain radiating through to the back. This was associated with temperature elevation to 101.6". A chest roentgenogram (Figure, A) revealed marked fluid at the left base and infiltrate, as well as pneumomediastinum. An esophagogram revealed perforation at the distal third of the esophagus 7 cm. above the diaphragm (Figure, B). When first seen by the thoracic surgical service 24 hours following the procedure, the patient had progressive temperature elevation as we11 as increasing left hydropneumothorax. She was given penicillin and chloromycetin intravenously and streptomycin intramuscularly. VOL. 8, NO. 1, JULY,

4 KAISER, BOWMAN, AND WYLIE A B C (A) Preoperative chest roentgenogram revealing left pleural efiusion and dilated esophagus in Case 3. (B) Close-up of esophagogram revealing dilated distal esophagus, with obstruction and leakage of contrast material into the left pleural space through a perforation. (C) Esophagogram four months postoperatively showing altered motility of the esophagus but no obstruction or delay of the passage of contrast material. Operation was performed approximately 30 hours following perforation and revealed foul-smelling purulent exudate in the left chest, with marked inflammatory response to the visceral and parietal pleurae. A I-inch perforation of the midesophagus on the posterolateral left wall was noted, with distal obstruction. No tumor mass was palpable, and it was believed that this obstruction was due to 78 THE ANNAIS OF THORACIC SURGERY

5 Esophageal Perforation with Distal Obstruction achalasia. A modified Thal procedure (esophagogastroplasty) [l 11 was performed to relieve the obstruction and close the esophageal perforation, with drainage of the left chest. Cultures of the fluid subsequently recovered Staphylococcus coagulase negative and Streptococcus. The patient slowly became afebrile in the postoperative period, and antibiotics were discontinued. The chest tube was removed on the eighth postoperative day. A cineesophagogram revealed intact distal esophagus. The patient was then given fluids and had progressed to a soft diet at the time of discharge. Subsequent cineesophagograms have revealed some evidence of motor dysfunction of the esophagus, without narrowing of the esophagogastric junction or delay at this site and without esophageal dilatation (Figure, C). There was no evidence of distal narrowing or reflux on two subsequent cineesophagograms. As of September 30, 1968, one year postoperatively, the patient was eating a regular diet and was occasionally taking antacids for mild retrosternal discomfort. T WELVE-YEAR EXPERIENCE These 3 cases are part of a larger series of 16 esophageal perforations occurring in 15 patients during a 12-year period from 1955 to 1968 at the Columbia Presbyterian Medical Center. In this disparate group of 16 cases, 3 were spontaneous esophageal perforations, and 13 occurred following instrumentation. Eight were in the cervical region and 8 in the intrathoracic portion of the esophagus. The incidence of esophageal perforation following instrumentation in the adult is 0.5% for the 2,400 elective endoscopies performed at this hospital during that time interval. This compares favorably with the 0.5% incidence of perforation reported for several thousand endoscopies performed in Sweden [l, 21. Surgical intervention was required in 13 patients. In 7 cases thoracic exploration was required; in 5 cases cervical drainage was instituted; and in 1 case both cervical drainage and thoracic exploration were performed. No surgery was done in 3 patients. There were no operative deaths. Of the 6 fatalities, 4 patients died of the extension of malignant disease during the present or subsequent hospital admission. One patient died suddenly following a spontaneous esophageal perforation associated with hyperemesis gravidarium in the immediate postpartum period. One patient died three weeks after perforation, with evidence of a retroesophageal abscess cavity. Treatment consisted of antibiotics given intravenously, tracheostomy, and the cessation of all feedings. This patient had nonmalignant disease, with duodenal ulcer and hiatal hernia, necessitating endoscopy. At that time a cervical perforation was thought to have occurred. This was the only patient fatality whose underlying disease was nonneoplastic in nature. It should be noted that the 3 patients with obstruction distal to esophageal perforation were operated on in the face of severe mediastinitis and pleuritis. In 2 cases the patients were over 70 years of age, had extensive esophagogastric carcinoma, and tolerated a palliative emergency esophagogastrectomy. In 1 of these cases, cultures showed no growth; in the second, the culture was a mixed flora of Staphylococcus coagulase negative, Escherichia coli, and Klebsiella pneumoniae. Both of these patients had a relatively uncomplicated postoperative course without evidence of an anastomotic leak or disruption, and were able to be discharged from the hospital with successful palliation lasting two months in 1 patient and six months in the other. In the third patient with distal obstruction and proximal perforation the disease process was achalasia. The patient had a large left pleural effusion, subsequent positive cultures for Staphylococcus coagulase negative and Streptococcus uiridans, and marked mediastinitis and pleuritis. A modified Thal procedure was performed, with a construction of esophagogastroplasty, i.e., a vertical incision at VOL. 8, NO. 1, JULY,

6 KAISER, BOWMAN, AND WYLIE the esophagogastric junction closed transversely with gastric serosa patching the defect. In this patient the postoperative period was uncomplicated, and at followup one year postoperatively there was some evidence of esophageal hypermotility but no narrowing at the distal esophagogastric junction and no cineesophagoscopic evidence of esophageal reflux, All 3 of these patients were treated with large doses of antibiotics, consisting of penicillin and chloromycetin given intravenously and streptomycin given intramuscularly. COMMENT This series illustrates certain important features in the management of esophageal perforation either due to instrumentation or occurring spontaneously in adult patients. It is of great importance to establish the underlying disease process and the state of esophageal pathology at the time of perforation. It must be established if there is esophageal obstruction distal to the site of perforation. In this circumstance the fistula will not heal and cannot be successfully treated by simple closure. Despite advanced age in 2 patients and the existence of the perforation for greater than 24 hours, successful definitive esophageal surgery could be performed. These results are similar to those reported by Kerr, whose three successful cases were reported recently 171. Two of his patients had benign stricture, and 1 had esophageal carcinoma. In 1 patient the operation was performed 48 hours after injury, but of the others, 1 was immediately following perforation and the other within 8 hours. In his review, Kerr cited 19 cases of esophagogastrectomy performed for instrumental perforation, with 16 successful cases and 2 operative deaths [7]. In the series reported by Johnson, early esophagogastrostomy was performed in 6 patients with distal esophageal obstruction and perforation [61. Five patients were successfully treated, and the authors advocated definitive operative intervention within six to eight hours of the perforation. In discussion, Hendren presented 4 successful cases 151. One patient was a 75-year-old woman with midesophageal carcinoma who underwent successful esophagogastrectomy. The other 3 patients were children. Two underwent successful colon interposition and 1 underwent esophageal resection with primary anastomosis for esophageal stenosis from differing causes, with proximal esophageal perforation. At present, the total reported experience shows 3 operative deaths in 35 cases (8.5%) associated with distal obstruction and proximal perforation. This figure compares favorably with that for primary esophagogastrectomy performed on an elective basis. In a series of 109 elective cases of esophagogastrectomy reported from Columbia Presbyterian Medical Center, the mortality rate was 11.9% [ THE ANNALS OF THORACIC SURGERY

7 Esophageal Perforation with Distal Obstruction SUMMARY Three cases of esophageal obstruction with proximal perforation were successfully treated by definitive surgery and drainage. Antibiotic therapy and the proper choice of surgical intervention have markedly lowered the incidence of mortality from this complication. REFERENCES Aniansson, G., and Hallen, 0. Perforations of esophagus. Acta Otolaryng. (Stockholm) 54:270, Elner, A., and Dahlbach, 0. Instrumental perforation of esophagus. Acta Otolaryng. (Stockholm) 54:279, Foster, J. H., Jolly, P. C., Sawyers, J. L., and Daniel, R. A. Esophageal perforation: Diagnosis and treatment. Ann. Surg. 161:701, Groves, L. K. Instrumental perforation of the esophagus. What is conservative management? J. Thorac. Cardiovasc. Surg. 52: 1, Hendren, W. H. Discussion of J. Johnson, C. Schwegman, and H. Mac- Vaugh [61. Johnson, J., Schwegman, C., and MacVaugh, H. Early esophagogastrostomy in the treatment of iatrogenic perforation of the distal esophagus. J. Thorac. Cardiovasc. Surg. 55:24, Kerr, W. F. Emergency oesophagectomy. Thorax 23:204, Logan, A. Mediastinum. In A. L. d Abreau (Ed.), Thorax. Chap. 15, p Vol. 5 of C. Rob and R. Smith (Eds.), Clinical Surgery. London: Edward, Magill, T. G., and Simmons, R. L. Resection of cardio-esophageal carcinoma. Arch. Surg. (Chicago) 94:865, Terracol, J., and Sweet, R. H. Diseases of the Esophagus. Philadelphia: Saunders, Pp Thal, A. P., and Hatafuku, T. Improved operation for esophageal rupture. J.A.M.A. 188:826, Wilkins, E. W., Jr., and Skinner, D. B. Surgery of the esophagus. New Eng. J. Med. 278:824, 887, DISC USSI 0 N DR. M. W. WHEAT, JR. (Gainesville, Fla.): Since Larry Groves, a member of this Society, reported the approach of primary esophageal resection in cases of perforated esophagus with distal obstruction three years ago, this method of management has received continued confirmation. The present report adds further confirmation. I wish to stress several points that I believe to be important in the general area of esophageal perforation, and then ask the authors several questions. First, I think the importance of prompt recognition of esophageal perforation and immediate definitive therapy cannot be overemphasized. We have seen 10 cases of esophageal perforation at the University of Florida. In 1 case cervical esophageal perforation was recognized immediately and the patient taken directly to the operating room, where repair was carried out. The patient had an afebrile course, healed per primam, and was discharged seven days later. This is in direct contrast to those in whom the perforations went unsuspected for several hours or days. Although there were no deaths, the patients were quite ill with the VOL. 8, NO. I, JULY,

8 KAISER, BOWMAN, AND WYLIE complications of mediastinal abscess, empyema, esophagocutaneous fistulas, and esophagobronchocutaneous fistulas. In the present report, 2 patients sustained perforations following esophageal biopsy where no lesion was seen. I have always believed that it is extremely hazardous to biopsy the esophagus if no lesion is seen. Therefore, these 2 perforations do not surprise me. The authors give a perforation percentage of 0.5% in 2,400 elective endoscopies. A more pertinent statistic would be, how many of the 2,400 endoscopies were esophagoscopies with perforation? Of the 3 patients in whom there was no surgical intervention, at least 2 died, according to the manuscript. I am curious as to what happened to the third pa tien t. Finally, although I understand this has also been changed in the final manuscript, the Thal procedure is not an esodhagogastrostomy. Esophagogastrostomy has come to be synonymous with esophagogastrectomy. The Thal procedure rather is an esophagoplasty with a gastric or fundic onlay patch graft. DR. ANDRE P. NAEF (Yverdon, Switzerland): I would like to mention another possible method of managing a perforated achalasia. Our patient was operated on approximately 10 to 12 hours after a blind bougienage perforation by a medical colleague. At operation we simply closed the perforation on one side of the cardia and did a definitive Heller procedure on the other, with a perfect postoperative result in all respects, both for the perforation and for the achalasia. This confirms the philosophy of immediate definitive surgery in these potentially very dangerous situations. DR. MICHAEL ROHMAN (Valhalla, N.Y.): I enjoyed this paper very much. It confirms the fact that in the face of perforations one can perform successful esophageal resections. Certainly in the presence of obstructive benign disease this approach should be considered. I believe, however, that a procedure of less magnitude should be employed for patients with extensive carcinoma. Primary resection of carcinoma of the esophagus with perforation, with extensive disease in the liver, mediastinum, and elsewhere, as a palliative procedure requires major surgery of considerable risk and morbidity for the patient with only short-term beneficial results. At Grasslands Hospital we have utilized the Fell tube successfully to obtund a spontaneous perforation of carcinoma of the esophagus and permit adequate alimentation in two patients. The clinical picture was that of spontaneous pneumothorax that responded to closed thoracotomy, although salivary and gastric drainage persisted. Esophagograms demonstrated perforations above the lesions, and Fell tubes were placed. Both patients survived, one for five months and the other for seven months with good palliation. I must conclude that a lesser palliative procedure is just as successful as resectional surgery in terms of survival and amelioration of symptoms. DR. KAISER: In answer to Dr. Wheat, the reason we included all the endoscopies is that in 2 of our patients the primary reason for endoscopy was a gastroscopic examination. In addition, the majority of endoscopic procedures performed at our institution are not done by the thoracic surgical service. This has occasioned some delay between the time the esophageal injury occurred and the time we saw the patient. As for Dr. Naef's question about the use of a Heller (cardiomyotomy) procedure for treatment of achalasia, in our patient the perforation caused a large tear greater than 1 inch in length, and we felt that a through-and-through incision including the area of the esophagogastric junction closed transversely (esophagogastroplasty) would insure relief of the obstruction due to achalasia. The gastric fundus was then sutured in place over the perforation closure in a modification of 82 THE ANNALS OF THORACIC SURGERY

9 Esophageal Perforation with Distal Obstruction the Thal procedure. I believe that Dr. Groves in his paper mentioned doing a Heller procedure for achalasia associated with esophageal perforation, and recently in New York, Drs. Sicular and Kirschner have reported 2 successful cases treated with a modification of the Heller procedure and closure of perforation. Finally, I believe that Dr. Rohman has described a satisfactory method of handling this serious problem of perforation with obstruction; however, I think there may be differences between his cases and ours. His cases were spontaneous perforations of neoplasm in the middle third. The indwelling tubes might be placed satisfactorily in this area but with more difficulty in the distal lesions. Certainly this would not be applicable in patients with achalasia. In addition, our particular experience with the use of indwelling tubes has not been extensive, and we have seen instances where the tubes themselves have caused perforation. NOTICE FROM THE SOUTHERN THORACIC SURGICAL ASSOCIATION Application for membership in the Southern Thoracic Surgical Association, on forms provided by the Association, should be sent directly to A. Robert Cordell, M.D. (Chairman of the Membership Committee), Bowman Gray School of Medicine, Winston-Salem, N.C , no later than September 1, Papers that are accepted for the program and that are to be considered for publication in the Annals should be submitted to the Editor by October 15, WI.. 8, NO. 1, JULY,