31: Techniques and Indications for Esophageal Exclusion

The four main causes of esophageal perforation are spontaneous perforation associated with protracted vomiting, also known as Boerhaave syndrome, iatrogenic injury from instrumentation, breakdown of esophageal reconstructions after esophagectomy, and penetrating trauma.^1-4 Regardless of the etiology, mediastinal contamination from salivary, gastric, and biliary secretions, with the associated bacteria, leads to both local and systemic inflammatory responses. If the perforation is not controlled promptly, it will give rise to sepsis, which if left untreated, nearly 100% of the time, will result in mortality within 1 week.^1,4,5 Despite advances in surgical technique and critical care over the past decades, esophageal perforation remains a challenging clinical problem. Early diagnosis and prompt surgical treatment are the hallmarks of successful outcome after spontaneous (i.e., Boerhaave syndrome) and iatrogenic esophageal perforation. Advocates for stenting, primary esophageal repair, drainage with a T-tube, esophageal exclusion, esophageal diversion, and esophagectomy with upfront reconstruction for perforations can be found. This chapter describes the techniques and indications for esophageal exclusion.

The extent of the inflammatory response depends on the location of the injury and the length of time from the injury, both of which correlate with extent of mediastinal contamination. Cervical perforations often are limited to the neck, resulting in minimal to absent mediastinal contamination. Such perforations are best managed by local drainage techniques.^1,6 However, intrathoracic and intra-abdominal perforations generally cannot be managed successfully by drainage alone and require either repair with diversion or exclusion in addition to drainage procedures. The choice whether to proceed with primary repair or with esophageal exclusion rests on multiple factors.

Numerous studies have shown that the length of time from injury to diagnosis is an important determinant of outcome. Cases diagnosed more than 24 hours after injury are associated with increased mortality.^1,2 The length of time from injury to diagnosis is proportional to the degree of mediastinal or abdominal contamination, the severity of inflammation and tissue edema, and ultimately, the need for esophageal diversion. Rather than focusing on absolute lengths of time, however, when formulating a plan for treatment, it is better to evaluate the patient as a whole, considering the extent of injury, the overall physiologic status of the patient, the quality of the tissues on exploration, and the underlying esophageal pathophysiologic process. Otherwise healthy patients who sustain iatrogenic perforation to the intrathoracic or intra-abdominal esophagus and are diagnosed immediately are ideal candidates for primary repair with drainage. Elderly, malnourished, septic patients on vasopressors who go undiagnosed for several days after perforation and on exploration are found to have “woody,” edematous, and inflamed tissues remain poor candidates for primary repair and are best served by diversion and drainage procedures.

Primary esophageal resection for perforation has been touted by some to produce superior mortality results to primary repair or diversion.^1,2,7 For the most part, however, these opinions emanate from older nonrandomized, retrospective studies that often do not adequately account for patient comorbidity. Clearly, resection remains an option for patients with extensive tissue destruction who require resection for control of sepsis. All too often, the primary objective of treating esophageal perforation—to have a patient who is alive at the end of the day—is forgotten.

For patients with an underlying primary esophageal malignancy, esophageal resection with or without reconstruction is a viable option depending on the physiologic status of the patient, the degree of obstruction, and the stage of the malignancy. Younger patients with early-stage disease, minimal mediastinal contamination, and good-quality tissues are best served by resection with immediate reconstruction. Older patients or those with poor physiologic reserve should be resected without immediate reconstruction. Patients with involvement of the esophagus and the airway are more appropriately managed with exclusion and diversion techniques or esophageal stenting (see Chapter 56).

Esophageal Exclusion

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.

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.

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.

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.

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.

Feeding Tubes

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.

The patient is supported throughout the postoperative period. The historical survival rate for exclusion and diversion procedures in a meta-analysis was 24%.¹ Although this survival rate is higher than that reported for primary repair and resective procedures, none of the studies is prospective, nor do they stratify patient comorbidities as discussed earlier. It is likely that those who underwent exclusion and diversion procedures had more comorbidities and were more likely to be septic with flora.

Once the patient has made adequate recovery, the loop cervical esophagostomy is closed at the minimum of 6 to 8 weeks postoperatively. If the esophagus has not been divided completely, the loop cervical esophagostomy can close spontaneously. However, more typically, the patient is taken to the operating room for closure. In these cases, the skin around the esophagostomy is incised, and the esophagus is mobilized. The esophagostomy then is closed with interrupted absorbable sutures in a transverse manner. A Jackson-Pratt drain is placed next to the esophageal closure. The platysma and skin are closed subsequently. A Gastrografin swallow is performed 7 to 10 days postoperatively before advancing the patient's diet.

Patients may develop late strictures at the site of perforation or where the stapled exclusion is performed. These strictures are managed with dilation procedures. Often retrograde dilation through the gastrostomy is required if the stricture cannot be passed antegrade, as has been described.⁸ Late strictures frequently require esophageal resection with reconstruction using either stomach or colon as a conduit.⁶

Despite advances in surgical technique and critical care, esophageal perforation remains a clinical challenge. Early diagnosis and prompt surgical treatment are the hallmarks of successful outcome. Esophageal exclusion and diversion techniques are needed in situations where patient and local tissue factors prohibit safe primary esophageal repair and drainage.

A 52-year-old woman was intubated at an outside hospital for 8 days for a drug overdose. A nasogastric tube was placed with minimal drainage. A left pleural effusion was noted for 7 days and partially drained with a pigtail catheter. After extubation on the eighth day, the patient had a chest CT scan that showed persistent left pleural effusion and a hiatal hernia. Subsequent barium swallow revealed a distal esophageal perforation with contrast material flowing freely into the left chest. The patient was transferred to our hospital for further management. On presentation, she appeared sick and had chest pain and an elevated white blood cell count. She was taken to the OR, and esophagogastroduodenoscopy was performed. The defect was identified in the distal esophagus. The patient underwent left thoracotomy. Two liters of bilious material was drained, and areas of necrotic parietal pleura were resected. The esophagus was noted to be edematous and inflamed. The esophagus could not be mobilized to fully identify the medial defect. Hence the esophagus was excluded proximal and distal to the perforation using TA and Endo-GIA knifeless staplers. Several chest tubes were placed to drain the chest. A gastrostomy and feeding jejunostomy were performed. The patient did well for 2 weeks but then developed renewed clinical signs of esophageal leakage. Chest CT scan revealed a persistent esophageal leak. At esophagogastroduodenoscopy, it was discovered that the proximal staple line had recanalized. A cervical esophagostomy was performed with resolution of the patient's sepsis. Several months later, the esophagostomy was taken down, and the esophagus was dilated at the stapled line of distal esophageal exclusion. The esophagus had healed completely.

When the patient is sufficiently ill to merit proximal esophageal exclusion, it is probably best to include distal exclusion. This can be accomplished by either thoracotomy or mini-laparotomy. An additional benefit of using an exclusion technique is that it minimizes the need for prolonged chest tube drainage, which can lead to erosion into critical structures. On occasion it is necessary to divert a patient for distal esophageal leak following a primary or reoperative antireflux procedure. Usually, it is possible to apply the stapling device and exclude the perforated segment (while placing drains around the repaired hole) completely through the abdominal incision. The medical status of the patient will determine whether a proximal diversion is required or if a nasogastric tube placed in the usual fashion or through a neck incision is sufficient.

When it comes to reversing the stapling, an endoscopic dilatation done sequentially in several sessions is usually sufficient. Additional perspective on this situation is also offered in Chapter 32 by André Duranceau.