Midthoracic esophageal perforations generally are explored via right thoracotomy through the fifth intercostal space (Fig. 31-1). One should consider harvesting an intercostal muscle flap on entry because it may be beneficial to buttress the repair with intercostal muscle.
Exploration of midthoracic esophageal perforation via right thoracotomy through the fifth intercostal space (left). Distal thoracic or intra-abdominal esophageal perforations via left thoracotomy incision through the seventh intercostal space (right).
Distal thoracic or intra-abdominal esophageal perforations can be approached via left thoracotomy incision through the seventh intercostal space with takedown of the diaphragm as needed (Fig. 31-1). After entry, the chest is thoroughly explored with full visualization of the extent of esophageal injury, often requiring sharp dissection of the overlying esophageal muscle to reveal the full extent of mucosal injury (Fig. 31-2). The degree of contamination and the nature of the esophageal injury and surrounding tissues are noted.
Sharp dissection of the overlying esophageal muscle at the site of visible perforation is often required to reveal the full extent of the underlying mucosal injury.
Debate persists as to whether both proximal and distal exclusions are needed. Some surgeons find that a gastric tube is sufficient for distal drainage of bile, whereas others prefer a distal exclusion. If the decision is made to proceed to esophageal exclusion, the mediastinal pleura is incised, and the esophagus proximal and distal to the perforation is mobilized as needed to facilitate exposure. If the plan is to close the perforation before exclusion and diversion, the esophageal musculature is dissected to define the extent of mucosal injury. The perforation then is repaired with interrupted sutures, and the repair may be buttressed by using a pleural flap or intercostal muscle pedicle. After the perforation has been repaired, the esophagus proximal and distal to the perforation is isolated and ligated either with a heavy absorbable tie or, more commonly, with a stapling device (Ethicon TA-30 stapler; Johnson & Johnson, Somerville, NJ) without division of the esophagus (Fig. 31-3).6 It is important to use the same stapling device for both the proximal and distal ligations because recanalization of the esophagus occurs at different rates for different staple thicknesses. This can lead to potential problems if the perforation has not healed prior to recanalization, with bile reflux of salivary and gastric or biliary secretions through recanalized segments. After the distal esophagus has been ligated, the thoracic cavity is well drained and irrigated, and the chest is closed. A nasogastric tube is left in the proximal esophagus for drainage.
Isolation and ligation of the esophagus are performed proximally or distally or both proximally and distally at the surgeon's discretion using a heavy absorbable tie or a stapling device without division.
Cervical Esophageal Diversion
Exclusion may not be possible in patients in whom the tissue is too edematous and inflamed to hold sutures or staples. In this case, the perforation can be left alone, with reliance on diversion and drainage to heal the tear. Alternatively, for large perforations, an esophagocutaneous fistula can be formed by placing a T-tube through the perforation, which is then tunneled outside the chest (Fig. 31-4).1,2 With adequate proximal and distal exclusion or diversion, the creation of an esophagocutaneous fistula is not necessary, and debate persists as to whether a T-tube either for primary repair or in the setting of exclusion or diversion is ever needed.
An esophagocutaneous fistula can be formed by placing a T-tube through the perforation, which is then tunneled outside the chest.
The patient is then turned supine with neck extension that is facilitated by placement of a towel roll under the patient's shoulders with the head turned to the right to expose the left neck. Both the neck and abdomen are widely prepped. The proximal esophagus is exposed through the left neck with an incision along the anterior sternocleidomastoid muscle (Fig. 31-5). The sternocleidomastoid muscle is retracted laterally. The strap muscles along with the middle thyroid vein are divided if needed. The carotid sheath then is identified and retracted laterally. The esophagus is palpated along the cervical spine and carefully encircled with a Penrose drain, with attention being paid to the recurrent laryngeal nerve to avoid injury.1,6 The esophagus then is mobilized proximally to the level of the cricopharyngeus muscle and distally to the thoracic inlet. The proximal esophagus then can be brought out through the bottom of the incision, with a transverse incision being made in the proximal esophagus that later will be matured as a loop esophagostomy. Before this is matured, the distal end of the cervical esophagus is isolated and ligated using either sutures or a stapling device (Fig. 31-6). After the distal cervical esophagus is ligated, the remaining cervical esophagus proximal to the ligated esophagus is brought out through the wound, a transverse or longitudinal incision is made in the esophagus, and the loop esophagostomy is matured using interrupted absorbable sutures (Fig. 31-7). Alternatively, the distal cervical esophagus can be ligated and divided, and an end esophagostomy can be matured. Although this eliminates the possibility of any proximal source of soilage, end esophagostomy requires a more extensive procedure when reestablishing esophageal continuity.
The cervical esophageal diversion is performed through the left neck with an incision along the anterior sternocleidomastoid muscle.
In preparation for the matured loop esophagostomy, the distal end of the cervical esophagus is isolated and ligated using either sutures or a stapling device.
Matured cervical esophagostomy with esophageal ostomy incorporated into the inferior edge of the neck incision.
The abdomen is explored through the midline if a right thoracotomy was used initially to explore the chest. It is important to explore the abdomen to ensure that the intra-abdominal esophagus has not been injured. If the intra-abdominal esophagus is injured, a gastrostomy is performed in addition to a feeding jejunostomy. The abdomen is then closed after irrigation, with placement of drains near the intra-abdominal esophageal perforation. Without any evidence of injury to the intra-abdominal esophagus, the gastrostomy may be omitted and only a feeding jejunostomy placed before the abdominal closure. However, typically, both a gastrostomy and jejunostomy are placed. Placement of a gastrostomy permits retrograde dilation of the esophagus if any stricture forms postoperatively.