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J Thorac Cardiovasc Surg 2005;130:1470-1471
© 2005 The American Association for Thoracic Surgery
Brief Communication |
Department of Surgery, Division of Thoracic Surgery, Virginia Commonwealth University, Richmond, Va.
Received for publication March 17, 2005; revisions received April 16, 2005; accepted for publication May 2, 2005. * Address for reprints: Andria Chambers or Jon Kiev, MD, West Hospital, 1200 E Broad St., 7th Floor, South Wing, Richmond, VA 23298. (Email: chambersas{at}mail2.vcu.edu; JKIEV{at}VCU.EDU).
We present the case of a 40-year-old man with spontaneous esophageal perforation following an episode of ethanol intoxication. The diagnosis of perforation was delayed due to refusal of intervention. Endoscopic examination of the upper part of the esophagus revealed the tear above the gastroesophageal junction. A Polyflex self-expanding coated stent (Willy Ruesch GMBH, Kernen, Germany) was placed, isolating and sealing the area of perforation and restoring esophageal continuity. A left thoracoscopy was performed to drain and debride the mediastinum. The patient was discharged eating a regular diet and the Polyflex stent was removed 1 month later.
This case is unique because a combined minimally invasive approach was used to manage a complex potentially fatal surgical emergency, which was previously handled through open thoracotomy. Because we combined video-assisted thoracic surgery and upper esophageal endoscopy, the patient experienced minimal morbidity and a short hospital stay with rapid return to activities of daily living. We believe this is the first reported case in which these combined modalities were used in the primary management of spontaneous esophageal perforation.
Clinical Summary
A 40-year-old man celebrated graduate school completion with an evening of hard liquor consumption. Three hours later, he began having indigestion and epigastric discomfort, followed by intermittent vomiting and retching. The patient was taken to his local hospital because of back pain and difficulty breathing.
On hospital arrival, decreased breath sounds on the left side were noted and the patient remained motionless throughout physical examination. A chest x-ray film revealed a left pleural effusion (Figure 1). No pneumothorax or subcutaneous emphysema was noted. Laboratory evaluation revealed a white blood count of 19,000. Esophageal perforation was confirmed on barium esophagogram approximately 3 hours after hospital admission with a distal esophageal leak and extravasation into the left side of the chest.
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Left thoracoscopy was performed with the left lung collapsed, and purulent pleural fluid was removed. The mediastinal pleura over the esophagus was boggy and inflamed. By use of sharp and blunt dissection, loculated and necrotic tissue was debrided back to healthy tissue followed by copious irrigation. Air and saline bubble insufflation revealed no extravasation after placement of the Polyflex stent. Multiple closed suction drains were placed adjacent to the area of injury.
The patient's postoperative course was unremarkable. A barium swallow confirmed esophageal continuity without extravasation of contrast. He resumed a soft diet before discharge. The Polyflex stent and percutaneous endoscopic gastrostomy tube were both removed 1 month later in the outpatient setting.
Comment
This case is unique in the use of minimally invasive techniques to manage a spontaneous esophageal perforation. Rather than perform thoracotomy, we elected to seal the esophageal leak by placing a self-expanding covered Polyflex stent with simultaneous video-thoracoscopic drainage and debridement.
1
The morbidity of the procedures was minimal and the patient's overall condition stabilized rapidly, allowing return to oral nutrition.
Traditionally, identification of the perforation site at thoracotomy with debridement of nonviable tissue is necessary before a buttressed repair with wide drainage.
2
The success in the management of esophageal perforations depends on the time interval to intervention, the cause and the site of the perforation, and control of mediastinal contamination and restoration of esophageal continuity.
3
This case illustrates unique management of a spontaneous esophageal perforation by combining minimally invasive video-assisted thoracoscopic surgery with use of a flexible endoscope. Thoracoscopic drainage and debridement with upper endoscopy placement of a Polyflex stent sealed the esophageal perforation. The patient did well and eventually returned for outpatient stent removal.
Spontaneous esophageal perforation may not require thoracotomy in all cases. In cases in which no underlying esophageal disease exists, a combination of upper endoscopy and thoracoscopy may allow adequate management of this patient population.
4
References
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