V

Figure 26-13 Technique of primary repair of esophageal perforation (continuation of Fig. 26-12). Traction sutures placed through the inflamed pouting mucosal edge of the tear elevate the submucosa so that an Endo-GIA cartridge can be applied and fixed (A and inset). The staple suture-line is covered by approximating the adjacent muscle over it from a running absorbable suture (B). (From Whyte, R.I., lannettoni, M. D., and Orringer, M.B.: Intrathoracic esophageal perforation: The merit of primary repair. J. Thorac. Cardiovasc. Surg., 109:140, 1994, with permission.)

Figure 26-14 Predicted intercostal muscle-flap reinforcement of esophageal suture line. The neurovascular bundle of the intercostal flap must be preserved. The muscle flap is sutured over the esophageal suture line as an "on-lay patch." The intercostal muscle pedicle should not be wrapped around the esophagus lest periosteal regeneration result in annular constriction and obstruction. (For purposes of illustration, a portion of the rib overlying the muscle pedicle has been removed.) (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, p. 272, with permission.)

Figure 26-15 Reinforcement of esophageal suture line with pericardial flap. (From Orringer, M.B.: Complications of esophageal surgery and trauma. In Greenfield, L.J. [ed. J: Complications in Surgery and Trauma. Philadelphia, J.B. Lippincott, 1984, p. 273, with permission.)

Figure 26-16 Gastrografin swallow showing midesophageal perforation (arrow) after rigid esophagoscopy in a patient who had dysphagia. An outside "normal" barium swallow report had been accepted, and esophagoscopy was performed without the endoscopist seeing the contrast study. In this patient, a large subcarinal mass of lymph nodes due to sarcoidosis was displacing the esophagus to the left, as is evident in this posteroanterior view. Without knowledge of this abnormal course of the esophagus in this patient, the esophagoscope was advanced, and a perforation occurred. The surgeon performing esophagoscopy is responsible for seeing the barium swallow examination in the patient before he or she passes the esophagoscope.

intercostal artery

Figure 26-17 A cervical esophageal perforation occurs as the rigid esophagoscope is advanced incorrectly. The esophagoscope must be lifted anteriorly (arrow) as the instrument is advanced through the sphincter to overcome the natural pull of the cricopharyngeus muscle against the cricoid cartilage and to avoid the typical posterior perforation (inset). (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, p. 267, with permission.)

TABLE 26-2 -- Complications of Hiatus Hernia Surgery

Intraoperative

Perforation

Endoscopic During dilation Vagus nerve injury Hemorrhage

Splenic injury Short gastric vessel Postoperative Perforation

Stricture

Esophageal suture Gastric suture

Dysphagia

Transient—"denervation," edema

Mechanical, fundoplication, gastroplasty tube, or hiatus too tight "Gas bloats"

Gastric atony—pylorospasm Crural repair disruption Postvagotomy diarrhea

Chylothorax

Incisional pain is disrupted during intraoperative dilatation. A delayed perforation, usually within 1 week of surgery, may occur when esophageal sutures placed too deeply during the repair result in local mural necrosis.

Acute esophageal tears recognized before the incision should be approached transthoracically and repaired, and the esophageal suture line reinforced with either the fundoplication if the tear is in the distal esophagus, the

Figure 26-18 A, Barium swallow examination in a 49-year-old man who was treated for a gunshot wound of the esophagus and trachea 23 years earlier. At that operation, the tracheal and esophageal holes were debrided and repaired, and the esophagus was incorrectly wrapped circumferentially with a mobilized intercostal muscle pedicle. Subsequent regeneration of cartilage from the perichondrium of the intercostal pedicle resulted in severe dysphagia and the high-grade upper esophageal stenosis with proximal esophageal dilation that is shown. B, Postoperative barium swallow after a repeat right thoracotomy and partial resection of the encircling cartilaginous and muscle ring. The lumen was greatly improved, and the dysphagia was relieved.

Figure 26-19 Acute strangulation of the incarcerated paraesophageal hiatal hernia, which is inherent in construction of a Thal-Woodward procedure. A Mild distal esophageal reflux stricture (arrow) proximal to a sliding hiatal hernia. B, Postoperative barium swallow after Thai fundic patch esophagoplasty combined with an intrathoracic Nissen-type fundoplication. C, Gastrografin swallow in same patient when he presented with acute chest pain and shortness of breath. There was gross dilation of the incarcerated intrathoracic stomach. Nasogastric decompression was required, and the patient was treated subsequently with a distal esophagectomy and short-segment colonic interposition.

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