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J Thorac Cardiovasc Surg 1994;108:393
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Late management of esophageal perforatio

Department of Thoracic and Cardiovascular Surgery
Helsinki University Central Hospital
Helsinki, Finland

Reply to the Editor:

Drs. Santos and Frater ¹ reported a very interesting technique to treat patients with mediastinitis caused by esophageal perforation. They irrigated the mediastinum through the perforation in the esophagus. Profuse transesophageal irrigation of the mediastinum was achieved with orally ingested fluid. If the patient could not drink, the mediastinal irrigation was accomplished with a nasogastric tube positioned in the upper esophagus proximal to the perforation and connected to a bottle containing saline solution that was allowed to drip at a rate sufficient to keep the mediastinum clean. More precise guidelines were not available either in the original article ¹ or in Dr. Santos' letter to the Editor.

Santos and Frater described eight patients who had a perforation not amenable to repair or a leak resulting from disruption of an attempted esophageal repair. It would be interesting to know how many primary repairs or other techniques were used during this time in their institution or whether these eight patients comprise their total experience with esophageal rupture. A critical examination of the series of patients presented by Santos and Frater ¹ reveals principal differences compared with our patients. ² Three of the eight patients had cervical esophageal rupture, which is a totally different condition from delayed septic perforation of the thoracic esophagus and has a very good prognosis even in delayed cases. The remaining five patients had rupture of the thoracic esophagus. All of our 34 patients ² had a perforation of the thoracic esophagus with mediastinal sepsis, and the mean delay in diagnosis was 4 days, whereas the patients of Santos and Frater were operated on 26, 30, and 36 hours after rupture. This means that their diagnoses were made earlier and the delay in diagnosis may have been less than 1 day. The longer the diagnosis and treatment are delayed, the greater the mortality. ³

Although the time factor and anatomic location are of critical importance in the prognosis of esophageal perforation, the size of the rupture also has an impact on the outcome. The size of the esophageal perforations in the report of Santos and Frater varied between 2.5 and 5 cm, whereas some of our patients had tears measuring 10 cm. ⁴ Taken all together, it is evident that the two series of patients are not comparable because of differences in the delay in diagnosis and the size of the perforations. Therefore no comparison of the reported therapeutic methods is possible.

I appreciate the interesting technique of transesophageal irrigation presented by Santos and Frater and hope that they report their results in delayed cases soon. However, I am dubious about its effectiveness. In delayed cases of mediastinitis the infection has spread far from the rupture in the mediastinum and pleural cavities. Open techniques (thoracotomy) allow exact placement of irrigation and drainage tubes, as well as careful cleansing of the mediastinum and both pleural cavities. Esophagectomy is nescessary to remove the often gangrenous esophagus and to prevent the esophagomediastinal reflux of digestive gastric and duodenal juices, as well as intestinal bacteria. Cervical esophagostomy diverts the swallowed salivary enzymes and bacteria. We continue to use esophagectomy and mediastinal irrigation with local and intravenous antibiotics for the treatment of patients with delayed esophageal perforations with mediastinal sepsis. In early cases primary repair is the method of choice. If the perforation is located in the distal esophagus the primary repair site should be covered with gastric fundus and in more proximal perforations with omentum or pleura. Fibrin sealant (Tisseel, Immuno AG, Vienna, Austria) may be used for additional security.

References

1. Santos GH, Frater WM. Transesophageal irrigation for the treatment of mediastinitis produced by esophageal rupture. J THORAC CARDIOVASC SURG 1986;91:57-62.
   
2. Salo JA, Isolauri JO, Heikkilä LJ, et al. Management of delayed esophageal perforation with mediastinal sepsis: Esophagectomy or primary repair? J THORAC CARDIOVASC SURG 1993;106:1088-91.
   
3. Orringer MB, Stirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg 1990;49:35-43.
   
4. Salo JA, Seppälä KMY, Pitkäranta PP, Kivilaakso EO. Spontaneous rupture and functional state of the esophagus. Surgery 1992;112:897-900.
   

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