Figure 27-7 Inadvertently swallowed brldgework. Attempted endoscopic removal resulted in extensive esophageal laceration and perforation, which was shown by the presence of mediastinal air. At exploratory thoracotomy, repair of the esophagus was not possible, and an esophagectomy with cervical esophagogastric anastomosis was carried out.
Figure 27-8 Delayed recognition of cervical esophageal perforation after attempted endotracheal intubation. The large abscess in the upper left thorax required transthoracic drainage.
Figure 27-9 Primary repair of esophageal perforation illustrating exposure of the esophageal perforation. A, Extension of the muscular tear proximal and distal to the injury to allow complete exposure of the mucosal defect. The inset demonstrates the damaged pouting mucosa initially seen on inspection of the injury. B, Mobilization of the submucosa away from the muscular coat to allow exposure of the defect surrounded by normal submucosa and both the proximal and distal extent of the mucosal injury by extension of the muscular tear. (From Whyte, R.I., Iannettoni, M.D., and Orringer, M.B.: Intrathoracic esophageal perforation: The merit of primary repair. J. Thorac. Cardiovasc. Surg., 109:140, 1995.)
Figure 27-10 Technique of primary repair of esophageal perforation illustrating (A) closure of the defect with GIA surgical stapler after mobilization and exposure of the mucosal and submucosal tear beyond the muscular tear, and (B) approximation of the muscular coat over the suture line with a running absorbable suture. The stapler is applied over an intraesophageal bougie (inset) to healthy mucosa and submucosa, not to the inflamed edges of the defect. (From Whyte, R.I., Iannettoni, M.D., and Orringer, M.B.: Intrathoracic esophageal perforation: The merit of primary repair. J. Thorac. Cardiovasc. Surg., 109:140, 1995.)
Figure 27-11 Repair of a distal esophageal perforation and reinforcement with fundoplication. The fundoplication has been reduced below the diaphragm to prevent complications of a paraesophageal hernia. A nasogastric tube, decompressing gastrostomy, and feeding jejunostomy have been added. (From Orringer, M.B.: Complications of esophageal surgery and trauma. In Greenfield, L.J. [ed.]: Complications in Surgery and Trauma. Philadelphia, J.B. Lippincott, 1984, with permission.)
Figure 27-12 Pleural flap patch closure of a large esophageal defect. A, After mobilization of the esophagus, a pleural flap is raised. B, The flap is placed around the esophagus, covering the perforation. C, The flap is sutured to itself. Sutures are placed above and below at the margins of the flap and also the perforation itself, tacking the pleura firmly to the esophageal muscularis. (From Gricco, H.C., and Wilkins, F.W.: Esophageal repair following late diagnosis of intrathoracic perforation. Ann. Thorac. Cardiovasc. Surg., 20:337, 1975, by permission of The Society of Thoracic Surgeons.)
Figure 27-14 Construction of an anterior thoracic esophagostomy to preserve maximal length of esophagus. A, The mobilized thoracic esophagus is placed on the anterior chest wall to determine the location of the stoma. B, The esophagus is then tunneled subcutaneously and the esophagostomy is constructed. Stomal appliances are easily applied to the flat surface of the chest, and the additional esophageal length provided by the technique often facilitates later reconstruction. (From Orringer, M.B.: Complications of esophageal surgery and trauma. In Greenfield, L.J. fed. J: Complications in Surgery and Trauma. Philadelphia, J.B. Lippincott, 1984, with permission.)
Figure 27-15 Technique of esophageal exclusion. A side cervical esophagostomy diverts oral secretions. Reflux of gastric and biliary secretions is prevented by an umbilical tape tied at the gastroesophageal junction. The tape is tied tightly enough to obstruct the lumen but not tight enough to cause mural ischemia. The vagus nerves are not included in the tie but lie superficial to it. (From Brewer, ¡.A., Carter, R., Mulder, G.A., and Stiles, Q.R..: Options in ¡he management of perforations of the esophagus. Am. J. Surg., 152:62, 1986, with permission.)
Esophageal perforation Is virtually always an Indication for surgery except In patients with well-contained leaks with good Internal drainage. A minority of patients with poorly contained disruptions have been treated successfully non-operatively with tube thoracostomy for drainage or tube thoracostomy combined with esophageal Intubation to occlude the esophageal tear.1 ' 1 ' Despite occasional success with these conservative methods, non-operative therapy is contraindicated in most patients with esophageal disruption, and an aggressive approach, if necessary using an esophagectomy in those with intrinsic esophageal disease, is often less "radical" treatment in the long run. Meticulous primary repair of esophageal disruption, regardless of the duration of the tear, is an established principle in the management of this disastrous injury.
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