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J Thorac Cardiovasc Surg 2003;125:976-977
© 2003 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki 00290, Finland

Reply to the Editor:

We thank Gaissert for his very valuable comments.

Spontaneous amputation of the esophagus is a serious and rare event, and its exact pathophysiology is not well understood. There were several reasons that led us to believe that intussusception, followed by ishemic necrosis, may be an etiologic factor. Our patient had a hiatal hernia, as previously stated. Hiatal hernia is a widely known risk factor for intussusception, as well as dysphagia, a condition that developed after severe vomiting. ¹ On careful inspection of Figure 1, one can see that the inner circular muscle layer of the esophagus is located superficially as a result of intussusception.

Abildgaard and associates ² have described total expulsion of the distal esophagus in a severely immunocompromised patient with Candida esophagitis. Multifactorial pathogenesis, including intussusception, is presumable inasmuch as their patient had also had regurgitation, vomiting, and nausea for at least 6 days before esophageal expulsion. Fungal necrosis of the esophagus may also have appeared secondarily. As we stated in our article, concomitant infections of the esophageal wall with Aspergillus may have contributed to the pathogenesis in our patient as well. There was no sign of perforation or esophageal fistula at esophagography, after the amputated segment was removed, and the patient was able to eat and drink for the next 4 weeks.

Gaissert recommends that esophageal resection, with immediate or delayed reconstruction, be performed to prevent mediastinitis and to restore swallowing, even in patients as seriously ill as ours. We use the previously described procedures ³ in cases with delayed perforation and rupture when the basic disease has a reasonable prognosis. Nevertheless, in our case, stricture and dysphagia were successfully palliated, at endoscopy, ⁴ with dilatation and the use of a self-expandable metallic stent. After this procedure, the patient's ability to swallow was almost normal until her death, a result of leukemic relapse, 8 months after the primary event.

References

1. Gowen GF, Stoldt HS, Rosato FE. Five risk factors identify patients with gastroesophageal intussusception. Arch Surg. 1999;134:1394-7.[Abstract/Free Full Text]
   
2. Abildgaard N, Haugaard L, Bendix K. Nonfatal total expulsion of the distal oesophagus due to invasive candida oesophagitis. Scand J Infect Dis. 1993;25:153-6.[Medline]
   
3. Salo JA, Isolauri JO, Heikkilä LJ, Markkula HT, Heikkinen LP, Kivilaakso EO, et al. Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair? J Thorac Cardiovasc Surg. 1993;6:764-7.
   
4. Toikkanen VJ, Nemlander AT, Rämö OJ, Salminen JT, Pekkanen AJ, Isolauri JO, et al. Expandable metallic stents in the management of malignant oesophageal obstruction. Ann Chir Gynecol. 2000;89:20-3.[Medline]
   

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