Management of Esophageal Perforation
Awide spectrum of strategies exists for management of esophageal perforation. Location (cervical, thoracic, or abdominal), nature of injury (iatrogenic, emetogenic), nature of esophageal tissue (normal or diseased), and length of time since perforation (immediate versus delayed) all influence choice of management. This chapter introduces some basic concepts of repair. It is included with material about surgery around the esophageal hiatus because any surgeon who operates in this region should be able to manage iatrogenic injuries that may occur during dissection. Wide drainage without repair or esophageal resection with immediate or delayed reconstruction are also options (see Chapters 30 to 32).
SCORE™, the Surgical council on Resident Education, classified procedures for esophageal perforation—repair/resection—as “ESSENTIAL UNCOMMON” operations.
STEPS IN PROCEDURE
Identify site of perforation
Extend opening in muscularis, if necessary, to expose entire extent of mucosal laceration
Perform layered repair
Reinforce the repair with adjacent well-vascularized tissue
Stomach, if lower esophagus
Pleural flap, if thoracic esophagus
Drain
HALLMARK ANATOMIC COMPLICATIONS
Failure to completely repair the laceration
Inadequate visualization of full extent of mucosal laceration
Mucosal laceration may be considerably longer than muscular laceration
Failure to adequately reinforce the repair
LIST OF STRUCTURES
Esophagus
Stomach
Fundus
Short gastric vessels
Parietal pleura
Intercostal muscles
Management of Distal Esophageal Perforation (Fig. 56.1)
Distal esophageal perforation may occur during dissection around the esophageal hiatus such as surgery for esophageal hiatus hernia. In these circumstances, the injury is fresh and the tissue is of good quality. Immediate recognition and repair with reinforcement of the suture line is appropriate. This is described here.
Mobilize the esophagus completely so that the perforation can be visualized. First ensure that you can see the full length of the mucosal laceration. The initial view of the injury may underestimate the length of the laceration (Fig. 56.1A). Do not hesitate to extend the laceration in the muscular layers until the full extent of the mucosal laceration can be seen (Fig. 56.1B). Perform a hand-sutured two-layer anastomosis.
Buttress the repair with the fundus of the stomach by performing a Nissen, Dor, or Toupet fundoplication (see Chapters 51 and 53). Alternatively, a flap of diaphragm can be developed and sutured over the laceration. This latter method is rarely used.
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